Tachyphylaxis Associated with Continuous Cisatracurium versus Pancuronium Therapy
作者:Salmaan Kanji、Jeffrey F. Barletta、James J. Janisse、James A. Kruse、John W. Devlin
DOI:10.1592/phco.22.11.823.33625
日期:2002.7
Study Objectives. To compare dosing requirements over time among patients receiving continuous cisatracurium versus pancuronium therapy, and to identify factors that may account for changes in pancuronium versus cisatracurium infusion requirements over time. Design. Retrospective, comparative cohort analysis. Setting. A tertiary level 1 trauma center. Patients. Forty-five consecutive adult patients who were admitted to intensive care units at our institution from January 1998–August 2000 and received continuous cisatracurium or pancuronium therapy for at least 48 hours. Measurements and Main Results. Dosing requirements of patients treated with pancuronium or cisatracurium were recorded over time throughout the treatment period. Factors that could affect dosing requirements of a neuromuscular blocking agent (NMBA) were stratified as time invariant (admitting service, acute physiology and chronic health evaluation II score, duration of mechanical ventilation, pressure control ventilation, baseline hepatic or renal insufficiency, thermal injury, train-of-four assessment, and concurrent drug administration or disorders affecting neuromuscular transmission) or time variant (concurrent sedation and narcotic analgesia therapy; serum magnesium, potassium, and creatinine concentrations; arterial pH level; temperature; peak airway pressure; and partial pressure of oxygen:fraction of inspired oxygen ratio). Hierarchical linear modeling was used to compare the dosing requirements and to identify confounders affecting the relationship. The infusion rate escalation for the cisatracurium group was greater (0.39 μg/kg/min; 95% confidence interval [CI] 0.22–0.56; 23 patients) than for the pancuronium group (−0.06 μg/kg/min; 95% CI −0.24-0.12; 22 patients; p<0.001) and was associated with an average daily cost/patient significantly higher (p<0.001) with cisatracurium ($258 ± $114) than pancuronium ($11 ± $5). Confounder analysis revealed that only the admitting service and the number of times the NMBA infusion was suspended because no twitch was detected differed between groups. Neither of these confounders significantly affected the temporal relationship between cisatracurium and pancuronium infusion rates. Conclusion. Dosing requirements increase over time at a significantly greater rate for cisatracurium than pancuronium infusions. Tachyphylaxis with cisatracurium is associated with substantial drug-related costs and is not accounted for by various disease-, patient-, and therapy-related factors. Further investigation is required to elucidate the mechanisms and risk factors underlying this phenomenon.
研究目的:比较接受连续施阿库氯铵与潘库溴铵治疗的患者在时间上的用药需求,并识别可能导致潘库溴铵与施阿库氯铵输注需求随时间变化的因素。
设计:回顾性比较队列分析。
设置:三级一级创伤中心。
患者:1998年1月至2000年8月在我院重症监护室住院的45名连续成人患者,接受连续施阿库氯铵或潘库溴铵治疗至少48小时。
测量和主要结果:记录接受潘库溴铵或施阿库氯铵治疗的患者在治疗期间的用药需求。可能影响神经肌肉阻滞剂(NMBA)用药需求的因素被划分为时间不变因素(入院科室、急性生理与慢性健康评估II评分、机械通气持续时间、压力控制通气、基础肝脏或肾脏功能不全、热伤害、四联反应评估,以及同时用药或影响神经肌肉传导的疾病)或时间变异因素(同步镇静和麻醉药物治疗;血清镁、钾和肌酐浓度;动脉pH水平;温度;峰气道压力;以及氧分压与吸入氧气分数的比率)。采用分层线性建模比较用药需求,并识别影响关系的混杂因素。施阿库氯铵组的输注速率上升幅度(0.39 μg/kg/min;95%置信区间[CI] 0.22–0.56;23名患者)大于潘库溴铵组(−0.06 μg/kg/min;95% CI −0.24-0.12;22名患者;p<0.001),与患者平均每日成本显著相关(p<0.001),施阿库氯铵为258 ± 114美元,潘库溴铵为11 ± 5美元。混杂因素分析显示,入院科室与因未检测到肌肉抽搐而暂停NMBA输注的次数在各组之间存在差异。这些混杂因素对施阿库氯铵与潘库溴铵输注率之间的时间关系没有显著影响。
结论:施阿库氯铵的用药需求随时间显著增加,增速显著高于潘库溴铵的输注。施阿库氯铵的迅速耐药性与可观的药物相关成本相关,且并未由各种疾病、患者和治疗相关因素解释。需进一步研究以阐明这一现象背后的机制和风险因素。