• Kristina Riley, Natalie Yampolsky, Zakaria Hakma, and Michael Moussouttas.
• Kristina Riley, Pharm.D., is Pharmacist, Capital Health Medical Center, Hopewell, NJ; at the time of writing she was Postgraduate Year 1 Pharmacy Resident, Capital Health Regional Medical Center, Trenton, NJ. Natalie Yampolsky, Pharm.D., BCPS, is Clinical Pharmacist, Neurosurgery/Critical Care, Capital Health Regional Health Center. Zakaria Hakma, M.D., is Neurosurgeon; and Michael Moussouttas, M.D., is Neurointensivist, Capital Institute for Neurosciences, Trenton.
• Am J Health Syst Pharm. 2015 Apr 15; 72 (8): 632-5.

PurposeA case of resistance to rocuronium and cisatracurium in a patient with a spinal injury who developed acute respiratory distress syndrome (ARDS) is reported.SummaryA 34-year-old, 88-kg Caucasian man with a history of polysubstance abuse fell from a bridge approximately 30-ft high, landing head first in about 2-3 ft of water. The patient sustained anterior subluxation at cervical spine levels C5-C6 and severe spinal canal compromise with cord compression and edema from C5 to C7, resulting in quadriplegia. The patient developed aspiration pneumonia for which he was given vancomycin and piperacillin-tazobactam. His pneumonia progressed to ARDS, and drug-induced paralysis was attempted to reduce barotrauma and improve ventilation. Rocuronium was initiated, but the patient did not adequately respond to this treatment. Cisatracurium was then initiated, but the patient did not respond. The decision was made to discontinue the cisatracurium infusion at that time and manage the patient's ARDS without a neuromuscular blocking agent (NMBA). After several attempts to manage the patient's ARDS by adjusting ventilatory values, the patient required the reinitiation of an NMBA. The decision was made to try cisatracurium again. Cisatracurium was again unsuccessful and therefore discontinued. As a last attempt to improve oxygenation, the patient received nitric oxide and sedation with propofol. The patient died due to his complicated hospital course that included quadriplegia, ARDS, cardiac arrest, and sepsis secondary to a gastric perforation.ConclusionInadequate paralysis was achieved with rocuronium and cisatracurium in a patient who sustained a significant trauma resulting in quadriplegia.Copyright © 2015 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

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