neuromuscular blockade

Summary

Summary: The intentional interruption of transmission at the NEUROMUSCULAR JUNCTION by external agents, usually neuromuscular blocking agents. It is distinguished from NERVE BLOCK in which nerve conduction (NEURAL CONDUCTION) is interrupted rather than neuromuscular transmission. Neuromuscular blockade is commonly used to produce MUSCLE RELAXATION as an adjunct to anesthesia during surgery and other medical procedures. It is also often used as an experimental manipulation in basic research. It is not strictly speaking anesthesia but is grouped here with anesthetic techniques. The failure of neuromuscular transmission as a result of pathological processes is not included here.

Top Publications

  1. Kocabas S, Yedicocuklu D, Askar F. The neuromuscular effects of 0.6 mg kg(-1) rocuronium in elderly and young adults with or without renal failure. Eur J Anaesthesiol. 2008;25:940-6 pubmed publisher
  2. Murphy G, Szokol J, Marymont J, Greenberg S, Avram M, Vender J. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg. 2008;107:130-7 pubmed publisher
    ..The aim of this investigation was to assess and quantify the severity of neuromuscular blockade in patients with signs or symptoms of critical respiratory events (CREs) in the PACU...
  3. Muenster T, Forst J, Goerlitz P, Schmitt H. Reversal of rocuronium-induced neuromuscular blockade by pyridostigmine in patients with Duchenne muscular dystrophy. Paediatr Anaesth. 2008;18:251-5 pubmed publisher
    ..Time to recovery of T(1) to 90% was not different between the groups (108, 63-134 vs 169. 61-208 min, respectively). Pyridostigmine 0.1 mg.kg(-1) effectively reversed a rocuronium-induced NMB in DMD patients. ..
  4. Arnberger M, Stadelmann K, Alischer P, Ponert R, Melber A, Greif R. Monitoring of neuromuscular blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting. Anesthesiology. 2007;107:903-8 pubmed
    ..b>Neuromuscular blockade during general anesthesia can be monitored with electrical peripheral nerve stimulation at the wrist...
  5. Illman H, Antila H, Olkkola K. Reversal of neuromuscular blockade by sugammadex does not affect EEG derived indices of depth of anesthesia. J Clin Monit Comput. 2010;24:371-6 pubmed publisher
    According to previous studies neuromuscular blockade may affect the depth of anesthesia...
  6. Blobner M, Eriksson L, Scholz J, Motsch J, Della Rocca G, Prins M. Reversal of rocuronium-induced neuromuscular blockade with sugammadex compared with neostigmine during sevoflurane anaesthesia: results of a randomised, controlled trial. Eur J Anaesthesiol. 2010;27:874-81 pubmed publisher
    ..This study compared the efficacy of sugammadex and neostigmine for reversal of neuromuscular blockade induced by rocuronium for facilitating elective surgery.
  7. Abrishami A, Ho J, Wong J, Yin L, Chung F. Cochrane corner: sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Anesth Analg. 2010;110:1239 pubmed publisher
    Sugammadex is the first selective relaxant binding agent that has been studied for reversal of neuromuscular blockade induced by rocuronium and other steroidal non-depolarizing neuromuscular blocking agents (NMBAs)...
  8. White P, Tufanogullari B, Sacan O, Pavlin E, Viegas O, Minkowitz H, et al. The effect of residual neuromuscular blockade on the speed of reversal with sugammadex. Anesth Analg. 2009;108:846-51 pubmed publisher
    ..modified gamma cyclodextrin compound which encapsulates rocuronium resulting in rapid reversal of residual neuromuscular blockade. We performed a post hoc analysis of data from a multicenter study designed to mimic standard clinical ..
  9. Duvaldestin P, Kuizenga K, Saldien V, Claudius C, Servin F, Klein J, et al. A randomized, dose-response study of sugammadex given for the reversal of deep rocuronium- or vecuronium-induced neuromuscular blockade under sevoflurane anesthesia. Anesth Analg. 2010;110:74-82 pubmed publisher
    ..of a new class of selective muscle relaxant binding drugs developed for the rapid and complete reversal of neuromuscular blockade induced by rocuronium and vecuronium...

More Information

Publications62

  1. Khuenl Brady K, Wattwil M, Vanacker B, Lora Tamayo J, Rietbergen H, Alvarez Gómez J. Sugammadex provides faster reversal of vecuronium-induced neuromuscular blockade compared with neostigmine: a multicenter, randomized, controlled trial. Anesth Analg. 2010;110:64-73 pubmed publisher
    ..relaxant binding drug that rapidly reverses rocuronium-induced and, to a lesser extent, vecuronium-induced neuromuscular blockade. In this study, we compared the efficacy of sugammadex and neostigmine for the reversal of vecuronium-..
  2. Dahl V, Pendeville P, Hollmann M, Heier T, Abels E, Blobner M. Safety and efficacy of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in cardiac patients undergoing noncardiac surgery. Eur J Anaesthesiol. 2009;26:874-84 pubmed publisher
    ..0 mg kg (n = 38), sugammadex 4.0 mg kg (n = 38) or placebo (n = 40) for reversal of rocuronium-induced neuromuscular blockade at reappearance of T2...
  3. Lardner D, Cox R, Ewen A, Dickinson D. [Comparison of laryngeal mask airway (LMA)- Proseal and the LMA-Classic in ventilated children receiving neuromuscular blockade]. Can J Anaesth. 2008;55:29-35 pubmed publisher
    ..mask airway (LMA)-Classic (CLMA) and LMA-Proseal (PLMA) in anesthetized children who have received neuromuscular blockade. Airway leak during intermittent positive pressure ventilation (IPPV) and adequacy of fibreoptic laryngeal ..
  4. Suzuki T, Mizutani H, Ishikawa K, Miyake E, Saeki S, Ogawa S. Epidurally administered mepivacaine delays recovery of train-of-four ratio from vecuronium-induced neuromuscular block. Br J Anaesth. 2007;99:721-5 pubmed
    ..6 (1.6) min vs 5.8 (2.1) min, P < 0.01]. In clinical anaesthesia, it should be recognized that epidurally administered mepivacaine delays considerably the TOF recovery from neuromuscular block. ..
  5. Murphy G, Szokol J, Marymont J, Greenberg S, Avram M, Vender J, et al. Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit. Anesthesiology. 2008;109:389-98 pubmed publisher
    Incomplete recovery from neuromuscular blockade in the postanesthesia care unit (PACU) may contribute to adverse postoperative respiratory events...
  6. Wu H, Ye T, Sun L. [Effects of atracurium pretreatment with magnesium on speed of onset, duration, and recovery of neuromuscular blockade]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2009;31:73-6 pubmed
    ..The onset time from the end of injection to maximum neuromuscular blockade was significantly shorter in magnesium group than in control group (P < 0.01)...
  7. Carvalho V, Braga A, Braga F, Loyola Y, de Araujo D, Mantovani M. The influence of lidocaine and racemic bupivacaine on neuromuscular blockade produced by rocuronium. A study in rat phrenic nerve-diaphragm preparation. Acta Cir Bras. 2009;24:211-5 pubmed
    To evaluate in vitro lidocaine and racemic bupivacaine effects in neuromuscular transmission and in neuromuscular blockade produced by rocuronium...
  8. Najafi A, Rahimi E, Shariat Moharari R, Hussain Khan Z. Bonfils fiberscope: intubating conditions and hemodynamic changes without neuromuscular blockade. Acta Med Iran. 2011;49:201-7 pubmed
    ..In the absence of NMBDs, Bonfils Intubation Fiberscope compares well with Macintosh laryngoscopy in terms of success rate and intubating conditions, but with less mechanical stress and hemodynamic compromise and longer intubation time. ..
  9. Warters R, Szabo T, Spinale F, DeSantis S, Reves J. The effect of neuromuscular blockade on mask ventilation. Anaesthesia. 2011;66:163-7 pubmed publisher
    We wished to test the hypothesis that neuromuscular blockade facilitates mask ventilation...
  10. Braga A, Carvalho V, Braga F, Rodrigues Simioni L, Loyola Y, Potério G. Influence of local anesthetics on the neuromuscular blockade produced by rocuronium: effects of lidocaine and 50% enantiomeric excess bupivacaine on the neuromuscular junction. Rev Bras Anestesiol. 2009;59:725-34 pubmed
    The effects of local anesthetics (LA) on neuromuscular transmission and their influence on the neuromuscular blockade produced by competitive neuromuscular blockers have not been fully investigated...
  11. Rex C, Wagner S, Spies C, Scholz J, Rietbergen H, Heeringa M, et al. Reversal of neuromuscular blockade by sugammadex after continuous infusion of rocuronium in patients randomized to sevoflurane or propofol maintenance anesthesia. Anesthesiology. 2009;111:30-5 pubmed publisher
    Sugammadex rapidly reverses neuromuscular blockade induced by bolus rocuronium doses, but it has not been investigated after continuous rocuronium infusion in surgical patients...
  12. Pühringer F, Rex C, Sielenkämper A, Claudius C, Larsen P, Prins M, et al. Reversal of profound, high-dose rocuronium-induced neuromuscular blockade by sugammadex at two different time points: an international, multicenter, randomized, dose-finding, safety assessor-blinded, phase II trial. Anesthesiology. 2008;109:188-97 pubmed publisher
    ..a novel, selective relaxant binding agent, was specifically designed to rapidly reverse rocuronium-induced neuromuscular blockade. The efficacy and safety of sugammadex for the reversal of profound, high-dose rocuronium-induced ..
  13. Puthucheary Z, Rawal J, Ratnayake G, Harridge S, Montgomery H, Hart N. Neuromuscular blockade and skeletal muscle weakness in critically ill patients: time to rethink the evidence?. Am J Respir Crit Care Med. 2012;185:911-7 pubmed publisher
  14. Claudius C, Viby Mogensen J. Acceleromyography for use in scientific and clinical practice: a systematic review of the evidence. Anesthesiology. 2008;108:1117-40 pubmed publisher
    ..A train-of-four ratio of 1.0 predicts with a high predictive value recovery of pulmonary and upper airway function from neuromuscular blockade.
  15. Arnot Smith J, Smith A. Patient safety incidents involving neuromuscular blockade: analysis of the UK National Reporting and Learning System data from 2006 to 2008. Anaesthesia. 2010;65:1106-13 pubmed publisher
    b>Neuromuscular blockade is a powerful anaesthetic tool that has the potential for significant adverse outcomes...
  16. Chittrakarn S, Keawpradub N, Sawangjaroen K, Kansenalak S, Janchawee B. The neuromuscular blockade produced by pure alkaloid, mitragynine and methanol extract of kratom leaves (Mitragyna speciosa Korth.). J Ethnopharmacol. 2010;129:344-9 pubmed publisher
    ..The effects of pure alkaloid, mitragynine and a methanolic extract of kratom leaves were investigated on neuromuscular junction and compound nerve action potential...
  17. Playfor S, Jenkins I, Boyles C, Choonara I, Davies G, Haywood T, et al. Consensus guidelines for sustained neuromuscular blockade in critically ill children. Paediatr Anaesth. 2007;17:881-7 pubmed
    The United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group is a multidisciplinary expert panel created to produce consensus guidelines on sedation, analgesia and neuromuscular ..
  18. Claudius C, Garvey L, Viby Mogensen J. The undesirable effects of neuromuscular blocking drugs. Anaesthesia. 2009;64 Suppl 1:10-21 pubmed publisher
    ..This article discusses the undesirable effects of the currently available neuromuscular blocking drugs including the definitions, diagnosis and causes of hypersensitivity reactions and postoperative residual curarisation. ..
  19. Yang L, Keam S. Sugammadex: a review of its use in anaesthetic practice. Drugs. 2009;69:919-42 pubmed publisher
    ..a modified gamma-cyclodextrin, is the first selective relaxant binding agent indicated to reverse the neuromuscular blockade induced during general anaesthesia to facilitate surgical procedures...
  20. Da Silva P, Neto H, de Aguiar V, Lopes E, de Carvalho W. Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children. Pediatr Int. 2010;52:438-43 pubmed publisher
    ..Thirty-four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P= 0...
  21. Plaud B, Meretoja O, Hofmockel R, Raft J, Stoddart P, van Kuijk J, et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients. Anesthesiology. 2009;110:284-94 pubmed publisher
    Sugammadex reverses neuromuscular blockade by chemical encapsulation of rocuronium...
  22. Akha A, Rosa J, Jahr J, Li A, Kiai K. Sugammadex: cyclodextrins, development of selective binding agents, pharmacology, clinical development, and future directions. Anesthesiol Clin. 2010;28:691-708 pubmed publisher
    ..This article reviews cyclodextrins, development of selective binding agents, clinical development, and future directions of sugammadex. ..
  23. Fuchs Buder T, Meistelman C, Alla F, Grandjean A, Wuthrich Y, Donati F. Antagonism of low degrees of atracurium-induced neuromuscular blockade: dose-effect relationship for neostigmine. Anesthesiology. 2010;112:34-40 pubmed publisher
    ..The purpose of this study was to investigate the dose-effect relationship of neostigmine to antagonize residual paralysis corresponding to a TOF ratio of 0.4 and 0.6...
  24. Herbstreit F, Peters J, Eikermann M. Impaired upper airway integrity by residual neuromuscular blockade: increased airway collapsibility and blunted genioglossus muscle activity in response to negative pharyngeal pressure. Anesthesiology. 2009;110:1253-60 pubmed publisher
    Residual neuromuscular blockade increases the risk to develop postoperative complications. The authors hypothesized that minimal neuromuscular blockade (train-of-four [TOF] ratio 0...
  25. Im S, Han S, Choi J, Lee J, Ko Y, Lee J, et al. Anatomic localization of motor points for the neuromuscular blockade of hand intrinsic muscles involved in thumb-in-palm. Am J Phys Med Rehabil. 2008;87:703-9 pubmed publisher
    ..The results may provide guidelines that could help in localizing the appropriate points for the neuromuscular blockade of thumb-in-palm muscles and, at the same time, help in minimizing the inadvertent block of the abductor ..
  26. Cammu G, de Kam P, Demeyer I, Decoopman M, Peeters P, Smeets J, et al. Safety and tolerability of single intravenous doses of sugammadex administered simultaneously with rocuronium or vecuronium in healthy volunteers. Br J Anaesth. 2008;100:373-9 pubmed publisher
    ..Rocuronium and vecuronium plasma concentrations decreased faster than those of sugammadex, reducing the theoretical risk of neuromuscular block developing over time. ..
  27. Dal Belo C, Colares A, Leite G, Ticli F, Sampaio S, Cintra A, et al. Antineurotoxic activity of Galactia glaucescens against Crotalus durissus terrificus venom. Fitoterapia. 2008;79:378-80 pubmed publisher
    ..Ethanolic extract of leaves of Galactia glauscescens (GGE) at concentration of 100 and 500 microg/ml prevented the neuromuscular paralysis induced by Crotalus durissus terrificus venom on mouse phrenic nerve-diaphragm preparation...
  28. von Ungern Sternberg B, Regli A, Frei F, Hammer J, Jordi Ritz E, Erb T. Decrease in functional residual capacity and ventilation homogeneity after neuromuscular blockade in anesthetized preschool children in the lateral position. Paediatr Anaesth. 2007;17:841-5 pubmed
    ..The impact of neuromuscular blockade remains unknown...
  29. Sparr H, Vermeyen K, Beaufort A, Rietbergen H, Proost J, Saldien V, et al. Early reversal of profound rocuronium-induced neuromuscular blockade by sugammadex in a randomized multicenter study: efficacy, safety, and pharmacokinetics. Anesthesiology. 2007;106:935-43 pubmed
    ..The efficacy, safety, and pharmacokinetics of sugammadex for reversal of profound rocuronium-induced neuromuscular blockade were evaluated...
  30. Harrison T, Sadnicka A, Eastwood D. Motor points for the neuromuscular blockade of the subscapularis muscle. Arch Phys Med Rehabil. 2007;88:295-7 pubmed
    ..This should lead to an increased efficacy and decreased side-effect profile in clinical practice, although clinical trials will need to confirm this. ..
  31. Munakata K, Suzuki T, Watanabe N, Nagai H, Kakishita M, Saeki S, et al. [Influence of epidural lidocaine injection on vecuronium-induced neuromuscular blockade]. Masui. 2004;53:1377-80 pubmed
    We investigated vecuronium-induced neuromuscular blockade in patients with continuous epidural lidocaine injection and those without epidural lidocaine...
  32. Koman L, Mooney J, Smith B, Walker F, Leon J. Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: a randomized, double-blind, placebo-controlled trial. BOTOX Study Group. J Pediatr Orthop. 2000;20:108-15 pubmed
    ..Patients in the BTX group demonstrated improved gait function and partial denervation of the injected muscle. No serious adverse events were reported. ..
  33. Plaud B, Debaene B, Donati F. The corrugator supercilii, not the orbicularis oculi, reflects rocuronium neuromuscular blockade at the laryngeal adductor muscles. Anesthesiology. 2001;95:96-101 pubmed
    ..In 12 other patients, laryngeal adductor neuromuscular blockade was assessed via the cuff of the tracheal tube and compared with the adductor pollicis and the corrugator ..
  34. Murray M, Cowen J, DeBlock H, Erstad B, Gray A, Tescher A, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2002;30:142-56 pubmed
  35. van Kuijk A, Geurts A, Bevaart B, Van Limbeek J. Treatment of upper extremity spasticity in stroke patients by focal neuronal or neuromuscular blockade: a systematic review of the literature. J Rehabil Med. 2002;34:51-61 pubmed
    Studies published from January 1966 until October 2000 on the clinical effects of focal neuronal and neuromuscular blockade in post stroke upper limb spasticity were identified...
  36. Erhan E, Ugur G, Gunusen I, Alper I, Ozyar B. Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade. Can J Anaesth. 2003;50:108-15 pubmed
    ..Propofol 2 mg x kg(-1) was superior to thiopentone 6 mg x kg(-1) and etomidate 0.3 mg x kg(-1) for tracheal intubation when combined with remifentanil 3 microg x kg(-1) and no muscle relaxant. ..
  37. Michaud G, Trager G, Deschamps S, Hemmerling T. Monitoring neuromuscular blockade at the vastus medialis muscle using phonomyography. Can J Anaesth. 2005;52:795-800 pubmed
    The vastus medialis muscle has been recently proposed as a new site for monitoring neuromuscular blockade (NMB)...
  38. de Boer H, Van Egmond J, van de Pol F, Bom A, Booij L. Reversal of profound rocuronium neuromuscular blockade by sugammadex in anesthetized rhesus monkeys. Anesthesiology. 2006;104:718-23 pubmed
    Reversal of neuromuscular blockade can be accomplished by chemical encapsulation of rocuronium by sugammadex, a synthetic gamma-cyclodextrin derivative...
  39. Cammu G, De Witte J, De Veylder J, Byttebier G, Vandeput D, Foubert L, et al. Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg. 2006;102:426-9 pubmed
    ..Although the incidence of residual paralysis was less frequent in surgical outpatients, predictive criteria were not evident. ..
  40. Goldmann K, Hoch N, Wulf H. [Influence of neuromuscular blockade on the airway leak pressure of the ProSeal laryngeal mask airway]. Anasthesiol Intensivmed Notfallmed Schmerzther. 2006;41:228-32 pubmed
    ..An intraoperative neuromuscular blockade could lead to a decrease of the airway leak pressure (P (leak)) secondary to the relaxation of the muscles ..
  41. Nigrovic V, Amann A. Competition between acetylcholine and a nondepolarizing muscle relaxant for binding to the postsynaptic receptors at the motor end plate: simulation of twitch strength and neuromuscular block. J Pharmacokinet Pharmacodyn. 2003;30:23-51 pubmed
    ..D] curves depend on (1) the affinities of D for the two binding sites, (2) the orientation of the affinities relative to those of A, and (3) the affinities of A for the same two sites. ..
  42. Kleinman B, Frey K, VanDrunen M, Sheikh T, DiPinto D, Mason R, et al. Motion of the diaphragm in patients with chronic obstructive pulmonary disease while spontaneously breathing versus during positive pressure breathing after anesthesia and neuromuscular blockade. Anesthesiology. 2002;97:298-305 pubmed
    ..During positive pressure ventilation (PPV) after anesthesia and neuromuscular blockade and depending on tidal volume, the nondependent region (top) undergoes the greatest excursion, or the ..
  43. Cerf C, Mesguish M, Gabriel I, Amselem S, Duvaldestin P. Screening patients with prolonged neuromuscular blockade after succinylcholine and mivacurium. Anesth Analg. 2002;94:461-6, table of contents pubmed
    ..a prospective cohort study in patients referred to our center between 1995 and 1999 for prolonged neuromuscular blockade after mivacurium or succinylcholine...
  44. Koman L, Brashear A, Rosenfeld S, Chambers H, Russman B, Rang M, et al. Botulinum toxin type a neuromuscular blockade in the treatment of equinus foot deformity in cerebral palsy: a multicenter, open-label clinical trial. Pediatrics. 2001;108:1062-71 pubmed
    ..BTX-A proved both safe and effective in the chronic management of focal muscle spasticity in children with equinus gait. ..
  45. Sacan O, White P, Tufanogullari B, Klein K. Sugammadex reversal of rocuronium-induced neuromuscular blockade: a comparison with neostigmine-glycopyrrolate and edrophonium-atropine. Anesth Analg. 2007;104:569-74 pubmed
    ..gamma] cyclodextrin compound, which encapsulates rocuronium to provide for a rapid reversal of residual neuromuscular blockade. We tested the hypothesis that sugammadex would provide for a more rapid reversal of a moderately profound ..
  46. Baillard C, Gehan G, Reboul Marty J, Larmignat P, Samama C, Cupa M. Residual curarization in the recovery room after vecuronium. Br J Anaesth. 2000;84:394-5 pubmed
    ..We conclude that it is necessary to antagonize residual block produced by vecuronium. ..
  47. Talke P, Caldwell J, Richardson C, Kirkegaard Nielsen H, Stafford M. The effects of dexmedetomidine on neuromuscular blockade in human volunteers. Anesth Analg. 1999;88:633-9 pubmed
    ..We found that the rocuronium concentration increased and the T1 response decreased during the dexmedetomidine administration. Although these effects were statistically significant, it is unlikely that they are of clinical significance. ..
  48. Niazi A, Leonard I, O Kelly B. Prolonged neuromuscular blockade as a result of malnutrition-induced pseudocholinesterase deficiency. J Clin Anesth. 2004;16:40-2 pubmed
  49. Satoh E. Ethyl acetate extract from black tea prevents neuromuscular blockade by botulinum neurotoxin type A in vitro. Int J Food Sci Nutr. 2005;56:543-50 pubmed
    ..These results indicate that ethyl acetate extract from black tea is the best source for searching for tea-derived inactivating substance(s) of botulinum neurotoxin. ..
  50. van Twest R. Bispectral index guided timing of intubation without neuromuscular blockade during sevoflurane induction of anaesthesia in adults. Anaesth Intensive Care. 2006;34:606-12 pubmed
    ..A target BIS value of 25 provides good to excellent intubating conditions and better intubating conditions than a target BIS of 40 during sevoflurane induction of anaesthesia without the use of neuromuscular blocking agents. ..
  51. Groudine S, Soto R, Lien C, Drover D, Roberts K. A randomized, dose-finding, phase II study of the selective relaxant binding drug, Sugammadex, capable of safely reversing profound rocuronium-induced neuromuscular block. Anesth Analg. 2007;104:555-62 pubmed
    The reversal of a deep neuromuscular blockade remains a significant clinical problem...
  52. Sparr H, Beaufort T, Fuchs Buder T. Newer neuromuscular blocking agents: how do they compare with established agents?. Drugs. 2001;61:919-42 pubmed
    ..In contrast to atracurium, cisatracurium does not undergo hydrolysis by nonspecific plasma esterases. Moreover, about 77% of the drug is cleared by organ-dependent mechanisms. ..
  53. Mascia M, Koch M, Medicis J. Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care. Crit Care Med. 2000;28:2300-6 pubmed
    ..the cost-effectiveness and safety of a set of rational use guidelines for analgesia, sedation, and neuromuscular blockade in critically ill ventilated patients when compared with similar factors in standard prescribing...