Neuromuscular Blockers and ARDS

Puthucheary, Zudin; Hart, Nicholas; Montgomery, Hugh

doi:10.1056/nejmc1011677

Cited by 10 publications

(6 citation statements)

References 9 publications

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“…Pathophysiologically immobility and local and systemic inflammation are believed to act synergistically to promote significant muscle loss in the critically ill patient [ 53 ]. Whilst the use of neuromuscular blockade agents has been previously cited as a risk factor, there remains no evidence for its association [ 62 ]—the only randomized trial performed showed no increase in ICU-AW following 48 h of paralysis [ 63 ], even in patients receiving concomitant steroids [ 64 ]. However, the relative contribution of each of these factors has not yet been established, and a full discussion on non-immobilization-related risk factors is beyond the scope of this review.…”

Section: Introductionmentioning

confidence: 99%

The impact of extended bed rest on the musculoskeletal system in the critical care environment

2015

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Prolonged immobility is harmful with rapid reductions in muscle mass, bone mineral density and impairment in other body systems evident within the first week of bed rest which is further exacerbated in individuals with critical illness. Our understanding of the aetiology and secondary consequences of prolonged immobilization in the critically ill is improving with recent and ongoing research to establish the cause, effect, and best treatment options. This review aims to describe the current literature on bed rest models for examining immobilization-induced changes in the musculoskeletal system and pathophysiology of immobilisation in critical illness including examination of intracellular signalling processes involved. Finally, the review examines the current barriers to early activity and mobilization and potential rehabilitation strategies, which are being, investigated which may reverse the effects of prolonged bed rest. Addressing the deleterious effects of immobilization is a major step in treatment and prevention of the public health issue, that is, critical illness survivorship.

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Section: Introductionmentioning

confidence: 99%

The impact of extended bed rest on the musculoskeletal system in the critical care environment

2015

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“…Contrary to earlier reports, the use of neuromuscular blockade agents are not associated with the development of ICU-AW (Puthucheary and Montgomery 2010;Papazian et al 2010). These earlier case reports were confounded by high dose corticosteroid use, and sedation and ventilation practises not used in modern critical care.…”

Section: Critical Illness Specific Risk Factorsmentioning

confidence: 62%

“…These earlier case reports were confounded by high dose corticosteroid use, and sedation and ventilation practises not used in modern critical care. The only randomised controlled trial to test this showed no increased incidence of ICU-AW (Papazian et al 2010) even with corticosteroids (Puthucheary and Montgomery 2010). NMBA use may even be beneficial, as a decrease in circulation inflammatory markers was noted (Forel et al 2006;Papazian et al 2010).…”

Section: Critical Illness Specific Risk Factorsmentioning

confidence: 98%

Muscle wasting in the critically ill patient: how to minimise subsequent disability

Flower

Puthucheary

2020

Br J Hosp Med

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Muscle wasting in critically ill patients is the most common complication associated with critical care. It has significant effects on physical and psychological health, mortality and quality of life. It is most severe in the first few days of illness and in the most critically unwell patients, with muscle loss estimated to occur at 2–3% per day. This muscle loss is likely a result of a reduction in protein synthesis relative to muscle breakdown, resulting in altered protein homeostasis. The associated weakness is associated with in an increase in both short- and long-term mortality and morbidity, with these detrimental effects demonstrated up to 5 years post discharge. This article highlights the significant impact that muscle wasting has on critically ill patients' outcomes, how this can be reduced, and how this might change in the future.

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“…7,21 The specific dosing regimen was based on previously published studies where 2 patients (out of 92 included) required a total dose of 37.5 mg/h in order to abolish all responses on train-of-four (TOF) stimulation. 8,9,27 TOF is the response after a peripheral nerve stimulator (PNS) that produces 4 stimuli with the potential to elicit 4 twitches. Traditionally, the TOF goal is 1 to 2 twitches equating to 80% to 90% receptor blockade.…”

Section: Controversiesmentioning

confidence: 99%

“…28 However, ACURASYS aimed at abolishing all responses on TOF, meaning authors aimed for a TOF of 0 out of 4. 27 Thus, NMBAs have been utilized as a flat-dose regimen because of the TOF response from 2 patients, potentially leading to excessive neuromuscular blockade.…”

Section: Controversiesmentioning

confidence: 99%

To Block or Not: Updates in Neuromuscular Blockade in Acute Respiratory Distress Syndrome

2020

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Objective: To review and evaluate neuromuscular blocking agents (NMBAs) in critically ill patients with acute respiratory distress syndrome (ARDS). Data Sources: A literature search utilizing PubMed was performed (January 1991 to January 2020) using the following search terms: ( neuromuscular blocking agents OR neuromuscular blockade OR cisatracurium OR rocuronium OR vecuronium OR pancuronium OR atracurium) AND * acute respiratory distress syndrome OR acute lung injury). Publications in English were evaluated. Study Selection and Data Extraction: Relevant clinical studies in humans were considered. Data Synthesis: Although NMBAs have been used for decades in the setting of ARDS, questions regarding mortality benefit remain. Early NMBA, within 48 hours of lung injury, have been historically used in critically ill patients with ARDS to aid in increasing alveolar recruitment, improving patient-ventilator synchrony, and promoting oxygenation by the prevention of contraction of respiratory muscles. Until recently, the literature showed an improvement in 90-day adjusted mortality. However, recent literature has demonstrated the lack of a mortality benefit. The continued receipt of NMBAs, with no clear benefit, could potentially lead to increased costs, skin breakdown, corneal abrasions, venous thromboembolisms, intensive care unit acquired weakness, and awareness with inappropriate sedation. Relevance to Patient Care and Clinical Practice: This review aims at discussing the preferred NMBA based on mechanism of action and reviews specific clinical trial data for the use of NMBAs in ARDS, clinical implications of these trial data, complications for the use of NMBAs, and needed future directions. Conclusions: The mortality benefit of NMBAs in ARDS has contradicting evidence with potentially serious adverse effects and notable controversies.

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Neuromuscular Blockers and ARDS

Cited by 10 publications

References 9 publications

The impact of extended bed rest on the musculoskeletal system in the critical care environment

The impact of extended bed rest on the musculoskeletal system in the critical care environment

Muscle wasting in the critically ill patient: how to minimise subsequent disability

To Block or Not: Updates in Neuromuscular Blockade in Acute Respiratory Distress Syndrome

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