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Critical care guidance relating to the Tier 3 Alert of supplies of Atracurium, Cisatracurium and Rocuronium

17 April 2020

Background

The additional pressure on Level 3 intensive care beds during the COVID-19 pandemic is creating additional demand for healthcare-related resources, including medicines.  It is particularly important that we try to manage use of key intensive care medicines during this time.  

A Tier 3 Supply Disruption Alert (SDA) was published on 16 April regarding the use of atracurium, cisatracurium and rocuronium. This advises that once supplies of atracurium and cisatracurium are exhausted locally over the coming days, Trusts will need to switch to the alternative rocuronium. It also advised that for patients undergoing tracheal intubation as part of a rapid sequence induction (RSI), Trusts should consider the use of suxamethonium, provided there are no contraindications, in order to preserve supplies of rocuronium.

This guidance is designed to provide additional advice to intensive care clinicians in managing the use of alternatives to atracarium/cisatracurium. The actions below are designed to preserve stocks of neuromuscular blocking agents (NMBAs), and to identify alternative practice where possible.

Actions

  • Consider the use of neuromuscular blocker agents (NMBAs) as an intravenous (IV) bolus dose initially to assess patient response before using an IV infusion.

  • Consider use of either rocuronium or pancuronium as the initial IV bolus NMBA

  • If continued NMBA therapy is required in the absence of atracurium or cistracurium, be prepared to use IV bolus regimens of rocuronium or pancuronium. Rocuronium continuous IV infusions may also be an appropriate option

  • Review the need for NMBA IV infusions at least daily and use the minimum dose possible, in conjunction with train of four (ToF) monitoring

  • Consider use of alternative modes of ventilation, in preference to use of NMBAs in cases of patient-ventilator dysynchrony, where the PF ratio allows.

General considerations

  • Patients should be sedated to a target SAS 1-2; RASS -4- - 5 (deep sedation) during continued NMBA administration. Consider objective sedation monitoring (e.g. BIS) if available.

  • Continue train of four (ToF) monitoring (if possible), in combination with clinical assessment, to assist with titration of NMBA infusions/ boluses and reduce the risk of NMBA accumulation. This reduces the potential for increased risk of critical illness myopathy and/or prolonged neuromuscular blockade.

  • Prolonged use of NMBAs may result in tachyphylaxis, so consider on a minimum daily basis whether continued use of NMBA is appropriate.

ENDS