Compared efficacy and tolerance of the neuromuscular blockade induced by brand-name (Nimbex®) and generic (Cisatrex®) of cisatracurium in mechanically ventilated critically ill patients: a crossover double-blind randomized study.

INTRODUCTION: use of generic drugs is common. However, there is still concern among patients and physicians that brand name drugs are more efficient. The aim of the study was to compare efficacy and tolerance between two forms of cisatracurium: brand name versus generic name. METHODS: it´s a crossover, randomized, double-blind physiological trial. Patients admitted for hypoxemic acute respiratory failure with PaO2/FIO2 < 200mmHg despite optimized ventilation and sedation thus requiring non-depolarizing neuromuscular blocking agents (NMBAs), were enrolled. Patients received consecutively, in a random order, cisatracurium brand name (Nimbex®) and generic (Cisatrex®) over two-hour period separated by one-hour washout period. Neuromuscular function was monitored by a calibrated train-of-four (TOF) stimulation device. Paralysis time delay to reach TOF of 2/4, recovery kinetics and tolerance were monitored. The number needed to demonstrate a significant difference in time delays to reach a TOF of 2/4 between the two forms of cisatracurium was estimated at 22 patients. RESULTS: twenty-two patients were included. Eight (36.4%) had acute respiratory distress syndrome; 8(36.4%), acute exacerbation of chronic obstructive pulmonary disease and 3(13.6%), status asthmaticus. Median [IQR] SAPS II at admission, 28.5 [22, 41]. PaO2/FIO2, 121 [81, 156] mmHg. Paralysis time delays were respectively, 80 [50, 112] vs. 87 [65, 115] minutes, in Nimbex® group and Cisatrex® group; (p=0.579). Within the recovery period, the between two-studied drugs´ difference in TOF was at 0.25±0.96; p=0.64. There were no significant hemodynamic differences. CONCLUSION: the present study revealed no significant differences in efficacy nor in tolerance between cisatracurium brand name Nimbex® and generic name Cisatrex® in hypoxemic ventilated patients.

Pulmonary Barotrauma Including Huge Pulmonary Interstitial Emphysema in an Adult with Status Asthmaticus: Diagnostic and Therapeutic Challenges.

INTRODUCTION: Pulmonary interstitial emphysema is a rare finding defined as abnormal air collection inside the lung interstitial tissues. Described more frequently in ventilated new-borns, pulmonary interstitial emphysema is an uncommon barotrauma-related complication in adults. Management and clinical sequelae are poorly described. PATIENT: We describe the case of a 64-year-old man who presented with huge pulmonary interstitial emphysema together with simultaneous pulmonary barotrauma in status asthmaticus requiring invasive ventilation. DISCUSSION: There are no guidelines for the management of such complications and their possible sequelae but conservative treatment seems to be effective. The treatment of our patient is described. LEARNING POINTS: We describe ventilation-induced tension pulmonary interstitial emphysema combined with contralateral pneumothorax, pneumomediastinum, pneumoperitoneum and subcutaneous emphysema which developed immediately after difficult airway management of acutely decompensated asthma in an adult.The present case highlights the importance of crash induction, cautious airway management and protective re-ventilation in the management of acute respiratory failure with dynamic hyperinflation, such as status asthmaticus.Minimally invasive management by percutaneous trans-thoracic intrabullous chest-tube drainage is feasible, safe and relatively effective.