Cisatracurium in "weakening doses" assists in weaning from sedation and withdrawal following extended use of inhaled isoflurane

UMMS Affiliation

Department of Pediatrics

Publication Date


Document Type



Anesthetics, Inhalation; Athetosis; Atracurium; Child, Preschool; Chorea; Follow-Up Studies; Intensive Care Units, Pediatric; Isoflurane; Neuromuscular Blocking Agents; Status Asthmaticus; Substance Withdrawal Syndrome; Time Factors; Treatment Outcome; Ventilator Weaning




OBJECTIVE: Isoflurane was used to treat a patient with status asthmaticus refractive to standard therapeutic measures. The patient developed a significant withdrawal syndrome when the isoflurane was weaned. A case is reported here where this withdrawal syndrome was treated successfully by using a weakening dose neuromuscular blockade with cisatracurium.

DESIGN: Case report.

SETTING: Pediatric critical care unit.

PATIENT: A 4-yr-old girl with severe reactive airways disease.

INTERVENTIONS: The use of weakening doses of cisatracurium to assist in weaning from mechanical ventilation in the setting of withdrawal symptoms following the extended use of inhaled isoflurane.

MEASUREMENTS AND MAIN RESULTS: Despite treatment with mechanical ventilation, intravenous corticosteroids, and bronchodilators for status asthmaticus, the patient required inhaled isoflurane. She became tolerant to isoflurane over an extended period of time; her tolerance was associated with a specific withdrawal syndrome, with the development of choreoathetoid movements resulting in poor pulmonary coordination and agitation. Conventional medical treatment of withdrawal failed. Finally, by using an infusion of cisatracurium at weakening doses to assist in the control of these choreoathetoid movements, the isoflurane and ventilator support were weaned.

CONCLUSIONS: Weakening doses of cisatracurium may be used safely to control unpleasant motor symptoms secondary to tolerance of isoflurane. This may have a use in other circumstances where agitation in mechanically ventilated patients is not due to pain or anxiety.

DOI of Published Version



Pediatr Crit Care Med. 2007 Jan;8(1):58-60. Link to article on publisher's site

Journal/Book/Conference Title

Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Related Resources

Link to Article in PubMed

PubMed ID