Cisatracurium Consumption Reduction Strategy

Issue: The purpose of this policy is to establish a best practice dosing strategy to conserve cisatracurium and decrease clinical variance within KHN. Cisatracurium is an ideal agent for patients requiring continuous paralysis, but product is currently unavailable nationwide with future availability uncertain. 

Background: 

• Cisatracurium is the neuromuscular blocking agent (NMBA) of choice for continuous infusion at KHN
  • Elimination mechanism provides predictable pharmacokinetics in the setting of organ dysfunction
  • Continuous infusion indications include acute respiratory distress syndrome (ARDS), ventilator dyssynchrony, and shivering during targeted temperature management post cardiac arrest

• Two dosing strategies used in the network for ARDS (Table 1)
  • Fixed dose (non-weight based, non-titratable) infusion based on the ACURASYS trial
    • Sixty-three percent (63%) ordered at Grandview Medical Center (Table 2)
  • Weight-based infusion titrated per train of four monitoring

• ACURASYS dosing strategy has been found to increase overall cisatracurium consumption compared to titratable drips with similar outcomes (paralysis and ventilator dyssynchrony)¹
  • Increased consumption is observed within KHN (Table 3)

• Recently published ROSE trial found no mortality benefit when utilizing ACURASYS regimen compared to intermittent paralysis²

Table 1

Cisatracurium Infusion Order Type, 2019	n (% total)
Fixed-rate infusion (ACURASYS)	104 (36%)
Weight-based, titratable	181 (64%)
Grand Total	285

Table 2

Fixed-rate infusion (ACURASYS), 2019	n (% total)
FORT HAMILTON HOSPITAL	9 (9%)
GRANDVIEW HOSPITAL	66 (63%)
GREENE MEMORIAL HOSPITAL	2 (2%)
KETTERING HOSPITAL	13 (13%)
SOIN MEDICAL CENTER	5 (5%)
SOUTHVIEW HOSPITAL	4 (4%)
SYCAMORE HOSPITAL	5 (5%)

Table 3

Cisatracurium Infusion Order Type	Average Number of 20mL vials used per patient
Fixed-rate infusion (ACURASYS)	6.54
Weight-based, titratable	2.76

Actions:

1. Limit use of cisatracurium to weight-based, titratable continuous infusions
   1. Remove ACURASYS from order entry
   1. Remove ACURASYS from pumps

• Utilize adjusted body weight for patients with body mass index ≥ 30 kg/m²
  • Recommended by Society of Critical Care Medicine³

References:

1. Hraiech S, Forel JM, Guervilly C, et al. How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study. Ann Intensive Care. 2017;7:79. doi:10.1186/s13613-017-0305-2
2. National Heart L, Blood Institute PCTN, Moss M, Huang DT, Brower RG, Ferguson ND, Ginde AA, Gong MN, Grissom CK, Gundel S, Hayden D, Hite RD, Hou PC, Hough CL, Iwashyna TJ, Khan A, Liu KD, Talmor D, Thompson BT, Ulysse CA, Yealy DM, Angus DC, (2019) Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. N Engl J Med 380: 1997-2008
3. Murray MJ, DeBlock H, Erstad B, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2016;44:2079-2103. doi:10.1097/CCM.0000000000002027