Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children

Silva, Paulo S.L. Da; Neto, Henrique Monteiro; Aguiar, Vânia Euzébio de; Lopes, Emílio; Carvalho, Werther Brunow de

doi:10.1111/j.1442-200x.2010.03104.x

Cited by 23 publications

(23 citation statements)

References 28 publications

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“…Finally, routine NMBA use during the early phase of ARDS was not associated with the risk of VAP. This is in contrast with some previous studies [25,30,31], in which NMBA use (for whatever duration) in nonselected mechanically ventilated ICU patients was associated with a higher risk of VAP.…”

Section: Discussioncontrasting

confidence: 99%

Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy

et al. 2012

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IntroductionVentilator-associated pneumonia (VAP) may contribute to the mortality associated with acute respiratory distress syndrome (ARDS). We aimed to determine the incidence, outcome, and risk factors of bacterial VAP complicating severe ARDS in patients ventilated by using a strictly standardized lung-protective strategy.MethodsThis prospective epidemiologic study was done in all the 339 patients with severe ARDS included in a multicenter randomized, placebo-controlled double-blind trial of cisatracurium besylate in severe ARDS patients. Patients with suspected VAP underwent bronchoalveolar lavage to confirm the diagnosis.ResultsNinety-eight (28.9%) patients had at least one episode of microbiologically documented bacterial VAP, including 41 (41.8%) who died in the ICU, compared with 74 (30.7%) of the 241 patients without VAP (P = 0.05). After adjustment, age and severity at baseline, but not VAP, were associated with ICU death. Cisatracurium besylate therapy within 2 days of ARDS onset decreased the risk of ICU death. Factors independently associated with an increased risk to develop a VAP were male sex and worse admission Glasgow Coma Scale score. Tracheostomy, enteral nutrition, and the use of a subglottic secretion-drainage device were protective.ConclusionsIn patients with severe ARDS receiving lung-protective ventilation, VAP was associated with an increased crude ICU mortality which did not remain significant after adjustment.

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Section: Discussioncontrasting

confidence: 99%

Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy

et al. 2012

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“…This limited use is not what we found for our early HFOV cohort, where the upper-risk quintiles received NMB for a median 53% of their ventilation time. Pediatric studies of prolonged use of NMB have shown increased mortality (28), duration of mechanical ventilation, and frequency of ventilator associated pneumonia (29).…”

Section: Discussionmentioning

confidence: 99%

Early High-Frequency Oscillatory Ventilation in Pediatric Acute Respiratory Failure. A Propensity Score Analysis

Bateman

Borasino

Asaro³

et al. 2016

Am J Respir Crit Care Med

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Rationale: The use of high-frequency oscillatory ventilation (HFOV) for acute respiratory failure in children is prevalent despite the lack of efficacy data.Objectives: To compare the outcomes of patients with acute respiratory failure managed with HFOV within 24-48 hours of endotracheal intubation with those receiving conventional mechanical ventilation (CMV) and/or late HFOV.Methods: This is a secondary analysis of data from the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) study, a prospective cluster randomized clinical trial conducted between 2009 and 2013 in 31 U.S. pediatric intensive care units. Propensity score analysis, including degree of hypoxia in the model, compared the duration of mechanical ventilation and mortality of patients treated with early HFOV matched with those treated with CMV/late HFOV.Measurements and Main Results: Among 2,449 subjects enrolled in RESTORE, 353 patients (14%) were ever supported on HFOV, of which 210 (59%) had HFOV initiated within 24-48 hours of intubation. The propensity score model predicting the probability of receiving early HFOV included 1,064 patients (181 early HFOV vs. 883 CMV/late HFOV) with significant hypoxia (oxygenation index >8). The degree of hypoxia was the most significant contributor to the propensity score model. After adjusting for risk category, early HFOV use was associated with a longer duration of mechanical ventilation (hazard ratio, 0.75; 95% confidence interval, 0.64-0.89; P = 0.001) but not with mortality (odds ratio, 1.28; 95% confidence interval, 0.92-1.79; P = 0.15) compared with CMV/late HFOV. Conclusions:In adjusted models including important oxygenation variables, early HFOV was associated with a longer duration of mechanical ventilation. These analyses make supporting the current approach to HFOV less convincing.

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“…It is clear nowadays that neuromuscular blockade of the diaphragm during mechanical ventilation has been associated with prolonged mechanical ventilation, a longer stay in the ICU, and a higher incidence of ventilator-associated pneumonia [40]. Surgical patients with residual muscle paralysis had postoperatively prolonged intubation times and weaning periods from the ventilator [41].…”

Section: Discussionmentioning

confidence: 99%

Molecular Response of the Human Diaphragm on Different Modes of Mechanical Ventilation

Dermitzaki¹,

Tzortzaki

Soulitzis

et al. 2012

Respiration

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Background: The mechanical stress that the human diaphragm is exposed to during mechanical ventilation affects a variety of processes, including signal transduction, gene expression, and angiogenesis. Objectives: The study aim was to assess the change in the production of major angiogenic regulators [vascular endothelial growth factor (VEGF), fibroblast growth factor-2 (FGF2), and transforming growth factor beta 1 (TGFB1)] on the human diaphragm before and after contraction/relaxation cycles during mechanical ventilation. Methods: This observational study investigates the diaphragmatic mRNA expression of VEGF, FGF2, and TGFB1 in surgical patients receiving general anesthesia with controlled mechanical ventilation (CMV) with muscle relaxation (group A, n = 13), CMV without muscle relaxation (group B, n = 10), and pressure support of spontaneous breathing (group C, n = 9). Diaphragmatic samples were obtained from each patient at two time points: 30 min after the induction of anesthesia (t₁) and 90 min after the first specimen collection (t₂). Results: No significant changes in the mRNA expression of VEGF, FGF2, and TGFB1 were documented in groups A and C between time points t₁ and t₂. In contrast, in group B, the mRNA levels of the above angiogenic factors were increased in time point t₂ compared to t₁, a finding which was statistically significant (p_VEGF = 0.003, p_FGF2 = 0.028, p_TGFB1 = 0.001). Conclusions: These findings suggest that the molecular response of the human diaphragm before and after application of diverse modes of mechanical ventilation is different. Angiogenesis via the expression of VEGF, FGF2, and TGFB1 was only promoted in CMV without muscle relaxation, and this may have important clinical implications.

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Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children

Cited by 23 publications

References 28 publications

Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy

Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy

Early High-Frequency Oscillatory Ventilation in Pediatric Acute Respiratory Failure. A Propensity Score Analysis

Molecular Response of the Human Diaphragm on Different Modes of Mechanical Ventilation

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