Neuromuscular Blockade in the Pediatric Intensive Care Unit: Pancuronium, Vecuronium, Rocuronium, or Atracurium

Abstract

Certain conditions may necessitate use of neuromuscular blocking agents (NMBAs) in children in the pediatric intensive care unit (PICU). Despite information concerning individual agents, there are limited studies comparing agents. I compare 4 of the more commonly used NMBAs: pancuronium, vecuronium, rocuronium, and atracurium. All agents were administered by bolus followed by a continuous infusion with the rate adjusted by use of a peripheral nerve stimulator to maintain one twitch of the train-of-four. Ten patients with normal hepatic and renal function were included in each group. The study period included the first 72 hours of neuromuscular blockade. All 4 agents were easily titrated by continuous infusion to maintain the desired level of blockade. Pancuronium infusion requirements varied from 0.03 to 0.12 mg/kg/hr, vecuronium requirements from 0.05 to 0.2 mg/kg/hr, rocuronium requirements from 0.5 to 1.9 mg/kg/hr, and atracurium requirements from 0.8 to 2.2 mg/kg/hr. No significant advantage of one agent over another was noted. The wide range of infusion requirements further stresses the need for close monitoring of the degree of neuromuscular blockade with a peripheral nerve stimulator. An additional 10 patients with abnormal hepatic/renal function received atracurium. The dose requirements were the same as in patients with normal end-organ function, ranging from 0.6 to 2.0 mg/kg/hr. In patients with abnormal hepatic or renal function, atracurium may be used without the need to alter the dose.