Hello, and welcome to this microlearning session. My name is Dr. Liza Barbarello-Andrews. I'm a clinical associate professor with the Ernest Mario School of Pharmacy at Rutgers, the State University of New Jersey, and a critical care pharmacy specialist with Robert Wood Johnson Barnabas Health. Over the next few minutes, I'm going to talk to you about strategies to mitigate the current shortages we're experiencing with neuromuscular blocking agents, or NMBAs. Please note that we will not be discussing the sedative and analgesic shortages that we are experiencing during COVID-19 in this segment, although the two topics are clearly and intimately related. Please see the separate program that's available for sedative and analgesic shortages. Cis-etrikerium is the most ideal non-depolarizing neuromuscular blocking agent for use in the ICU. It has an intermittent onset of about 2-3 minutes and a duration of about 40-60 minutes. It undergoes Hoffman elimination, allowing avoidance of prolonged paralysis in the setting of renal and hepatic impairment. Additionally, when we consider the structure of the agents, cis-etrikerium is a benzyl isoquinoloneum moiety, whereas vecuronium and rocuronium are both aminosteroidal moieties. This is clinically pertinent because additive steroid side effects can occur with the combined use of aminosteroidal agents and corticosteroids, but not when used in combination with cis-etrikerium. Unfortunately, cis-etrikerium is also the agent for which shortages are most severe during COVID-19. Rocuronium and vecuronium are the alternative agents to consider, but neither have characteristics as ideal as cis-etrikerium. Neither undergoes Hoffman elimination, so are at risk of prolonged paralysis with end-organ dysfunction. Both are hepatically metabolized, and vecuronium, as well as its active metabolite, are additionally renally eliminated. Mitigation strategies rely on ensuring the use of the most optimal agent available for a given patient in the most targeted fashion that applies the minimum amount of agent required. The use of paralytics as continuous infusions, while appropriate in some circumstances, is not an evidence-based standard of care. Therefore, one of the primary considerations for conserving cis-etrikerium is to only use infusions in those who fail intermittent strategies. When intermittent therapy does not meet clinical goals and an infusion is required, always consider patient characteristics when selecting an agent. If your institution has cis-etrikerium, it is best to reserve it for those requiring infusions. If your cis-etrikerium supply is depleted, select rocuronium in the setting of acute kidney injury or renal compromise to avoid prolonged paralysis. To wrap up, I'm going to provide you with mitigation strategies developed by two different organizations. You'll note that both are structured quite differently, but apply these core concepts. Because paralytic therapy is high-risk therapy not routinely used in today's ICUs, these strategies notably guide agent selection while also reinforcing application of related best practices, including titrating to ventilator synchrony instead of Trana4, and assuring concomitant deep sedation, analgesia, and supportive measures such as eye care. Seen here is the example from Robert Wood Johnson Barnabas Health, the organization where I practice. This was developed in collaboration with our critical care pharmacy specialists and intensivists. Although structured differently, you can see that the guideline provides key information for agent selection and prescribing, as well as the key reminders for titration, deep sedation, analgesia, and supportive care. Although mitigation strategies can be structured in different ways, they should foster intermittent strategies first, provide guidance for selecting agents, and reinforce best practices related to titration and adjunctive therapies. I hope this microlearning presentation has provided you with useful information for managing paralytic shortages during COVID-19. Thank you for listening!

neuromuscular blocking agents

shortages

COVID-19 pandemic

Cis-etrikerium

intermittent therapy