Anaesthetic guidance relating to Tier 3 Alert of supplies of Atracurium, Cisatracurium & Rocuronium

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Anaesthetic guidance relating to 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 COVID19 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), clinicians should consider the use of suxamethonium, provided there are no contraindications, in order to preserve supplies of rocuronium.

The Faculty of Intensive Care Medicine has produced guidance 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.

The alert also has implications for anaesthetic practice, as rocuronium is a first line drug for paralysis in rapid sequence induction, which is the preferred technique for general anaesthesia in patients with known and suspected COVID-19 and is used frequently in patients at low risk of COVID-19 who have not been tested.

Actions

Use regional or neuraxial techniques wherever practicable.
Consider using suxamethonium for neuromuscular blockade for rapid sequence induction provided there are no contraindications (NB caution in patients being intubated for transfer to ITU).
Suxamethonium administration can cause a significant rise in serum potassium, particularly in critically unwell patients. Levels should be measured prior to use in these and other susceptible patients.
Consider the use of remifentanil as an adjunct during intubation if appropriate
Consider whether there is a need for further paralysis after tracheal intubation.
Consider whether remifentanil could be used after tracheal intubation instead of a neuromuscular blocking drug.
In selected patients who have recently tested negative or are at low risk of COVID-19 infection, the use of a second generation supraglottic airway may be a suitable alternative to intubation.
Use commercially prefilled syringes of suxamethonium (if available) in areas in which the drug needs to be readily available but is not often used, eg obstetrics.

ENDS