What is the reason for the ineffective or insignificant effect of Neuromuscular relaxants such as Atracurium and anesthetics such as Ketamine on patients with Coronavirus hospitalized in the intensive care unit who have been treated with these drugs for a long time?
p.s : I saw in the hospital in the intensive care unit that these drugs do not work on patients and I wanted to know the reason or to be informed about other methods in this area.
Best Regards
Morteza
This is the first time I read about this issues. No previous reports of inefficacy of these drugs in Coronavirus patients. If this is confirmed with atracurium, it may be due to abnormal plasma pH or body temperature (both affects Hoffmann;s degradation). Still, no explanation for ketamine.
As Sherif Sultan has also said,this is the first time I've seen any such report,anecdotal or otherwise.
In our experience,across our regional network,we have had no issues with muscle relaxants,sedatives,or other anaesthetic drugs not working.
You do not offer any description of the issue other than the rather vague "I saw in the hospital in the intensive care unit that these drugs do not work on patients".
In itself this offers no information,and does not exclude factors such as suboptimal dosing,nor does it exclude variations in effect due to age,fitness,metabolic capacity etc.
Dear Sherif Sultan and Ian Ewart, Thank you for your answer,
The whole issue was as follows,
Three patients are under my care in the intensive care unit. Due to the decrease in the level of consciousness and also the severe involvement of their two lungs, intubation was inserted. Patients were also connected to a ventilator with SIMV ventilation mode. As you know, patients undergoing mechanical ventilation should be sedated with anesthetics, neuromuscular relaxants, and narcotics. Medications used for sedation included atracurium at a dose of 10 mg per hour, fentanyl 50 to 100 micrograms per hour, propofol up to 48 hours at a dose of 5 mg per kg, ketamine 200 mg per hour. Yesterday, for a 35-year-old man, Atracurium was replaced by Cis Atracurium, which still has little effect on preventing the patient from fighting the ventilator. Meanwhile, among these three patients, only one patient has a body temperature of 38.5, but the rest of the patients have degrees between 36.5 and 37.5. Three days ago, one of the patients unfortunately suffered from emphysema on the right side of the neck and emphysema spread to the right chest. This emphysema occurred after re-intubation following the closure of the tracheal tube due to a clot.
Another case is the percentage of emphysema in hospitalized patients for unknown reasons, and most patients are aged 30-45 years. So, considering my work experience in the hospital, which is about 8 years, I have seen the least emphysema.
Ventilator ventilation mode varies more between SIMV, PSV depending on the condition of the patients. PEEP usually varies between 5-15 but is mostly in the range of 10. PS is between 12-15 which is still variable. RR decreases or increases according to ABG results. The current volume of VT varies according to the patient's weight, which is 450-500 in these patients, which is reduced to 400 in patients with emphysema. PEEP is also reduced.
Drugs used include Pantoprazole, Dexamethasone, Recjen (interferon), Keltra, Sovodac, Ramsedi, Vancomycin, Ceftazidime,
These drugs are part of a medication protocol for patients that some patients may receive other medications.
Regards
Morteza
I think looking at what you've disclosed is that your dose regime may be one issue,and in one case,body temperature.
You state that most of your patients have been in the 30-45 year group,and you may well find that 10mg/hr is a very low dose of atracurium to achieve muscle relaxation.
I think also that 50-100mcg/hr of fentanyl may be suboptimal for many young patients.
We commonly use remifentanil,propofol (and clonidine when required),and try to avoid muscle relaxation wherever possible and to use patient triggered and supported ventilator modes.
Adequate sedation in young patients is often difficult to achieve,and may require the use of higher doses,and titration of those to achieve a desired effect.
Protocols,whilst very useful,may also need to be adapted for such patients,to take that into account.
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