title: Cisatracurium in "weakening doses" assists in weaning from sedation and withdrawal following extended use of inhaled isoflurane.
abstract: 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.
  
  
  METHODS
  Case report.
  
  
  METHODS
  Pediatric critical care unit.
  
  
  METHODS
  A 4-yr-old girl with severe reactive airways disease.
  
  
  METHODS
  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.
  
  
  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.
authors.affiliation: St. Mary's Hospital, London, UK.
authors.forename: Mehrengise K
authors.initials: MK
authors.lastname: Cooper
authors.forename: Scot T
authors.initials: ST
authors.lastname: Bateman
mesh_terms: D018685:Anesthetics, Inhalation / Q000009:adverse effects*; D001264:Athetosis / Q000139:chemically induced*; D001279:Atracurium / Q000008:administration & dosage / Q000031:analogs & derivatives*; D002675:Child, Preschool; D002819:Chorea / Q000139:chemically induced*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015278:Intensive Care Units, Pediatric; D007530:Isoflurane / Q000009:adverse effects*; D009466:Neuromuscular Blocking Agents / Q000008:administration & dosage*; D013224:Status Asthmaticus / Q000188:drug therapy*; D013375:Substance Withdrawal Syndrome / Q000188:drug therapy*; D013997:Time Factors; D016896:Treatment Outcome; D015300:Ventilator Weaning
chemical_list: D018685:Anesthetics, Inhalation; D009466:Neuromuscular Blocking Agents; D001279:Atracurium; D007530:Isoflurane; C101584:cisatracurium