Neuromuscular blockers and ARDS: Thou shalt not breathe, move, or die!

Yegneswaran, Balaji; Murugan, Raghavan

doi:10.1186/cc10470

Cited by 12 publications

(8 citation statements)

References 13 publications

(17 reference statements)

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“…[19][20][21][22] Studies also suggest decreased incidence of barotrauma and ventilator induced lung injury with the use of NMBAs. 8,21 However, all these authors had studied adult patients. Mortality in our study control group was 46.7% (14/30).…”

Section: Discussionmentioning

confidence: 99%

Early Neuromuscular Blockade in Children with Pediatric Acute Respiratory Distress Syndrome

Chandra

Goel

Dawra

2020

J Pediatr Intensive Care

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Pediatric acute respiratory distress syndrome (PARDS) is a challenging problem with high mortality. Role of neuromuscular blockade in the management of ARDS to date has been controversial, and this study was done to study the role of neuromuscular blockade in children having PARDS and development of associated complications, if any. This was a prospective, case–control study conducted in the pediatric intensive care unit (PICU) of a tertiary care teaching hospital, over a period of 24 months. Patients of age 1 to 18 years who presented with or developed PARDS during their course of hospitalization were included after written informed consent was obtained from their parents and/or guardians. Patients with PARDS requiring invasive mechanical ventilation were partitioned into a case group and a control group. Case group patients were sedated and paralyzed using midazolam (1 µg/kg/min) and vecuronium (1 µg/kg/min), respectively, along with institution of definitive management. Control group patients were given definitive and supportive therapy, but no neuromuscular blocking agents (NMBAs). All patients were followed up for signs and symptoms of myopathy or neuropathy during the entire duration of hospital stay and up to 3 months after discharge. During the study period, 613 patients were admitted to the PICU of which 91 patients qualified as having PARDS. Sepsis was the main etiology in 67 of the 91 patients (73.6%) with PARDS. Fifty-nine patients were included in the study, of which 29 patients were included in the case group and 30 patients were included in the control group. Among the 29 case group patients, 25 patients (86.2%) were successfully extubated. Four patients from the case group expired, while 14 out of 30 control group patients (46.7%) expired. Hypotension was present in 26 case group patients (89.6%), of which all showed resolution within 48 hours of definitive treatment. The mean time to resolution of hypotension was 41.6 hours (standard deviation [SD]: 5.759; range: 24–48) for case group patients, significantly lower (p < 0.0001) than the mean time to resolution of 103 hours (SD: 18.995; range: 90–126) for the 10 control group patients with hypotension that survived. Mean oxygenation index (OI) following 48 hours of vecuronium therapy was significantly lower (p < 0.0001; 95% confidence interval: 5.9129–9.9671) than mean OI at admission for case group patients. None of the patients receiving vecuronium exhibited neuromuscular deficit during their hospital stay, at time of discharge, or at follow-up evaluation up to 3 months after discharge. In this study, pediatric cases diagnosed with PARDS and managed with mechanical ventilation and vecuronium therapy had improved mean OI following 48 hours of NMBA therapy and a lower mortality when compared with matched control group patients. Incidence of NMBA-related weakness was not commonly observed in these patients.

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Section: Discussionmentioning

confidence: 99%

Early Neuromuscular Blockade in Children with Pediatric Acute Respiratory Distress Syndrome

Chandra

Goel

Dawra

2020

J Pediatr Intensive Care

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“…In patients with ARDS, early administration of NMBAs may be beneficial in reducing ventilator-induced lung injury through the prevention of spontaneous breathing 17 . It has been suggested that they may be protective in mechanical ventilation by allowing the tidal volume and pressure levels to be easily adjusted through preventing the patient working against the ventilator 18 . An alternative theory is that NMBAs may work by reducing the inflammatory response that occurs in early ARDS 19 .…”

Section: Resultsmentioning

confidence: 99%

Cisatracurium for acute respiratory distress syndrome: review of current evidence

Woodhouse¹,

Jonas²,

Szakmány³

2013

OA Critical Care

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I 2 = 0%), overall mortality (RR = 0.73, 95% CI = 0.57-0.92, I 2 = 0%), number of cases of new-onset barotrauma (RR = 0.43, 95% CI = 0.2-0.9, I 2 = 0%) and number of ventilator-free days (MD = 1.91, 95% CI = 0.28-3.55, I 2 = 0%). However, they did not show any significant effect on the duration of mechanical ventilation (RR 1.14, 95% CI =-4.07-6.35, I 2 = 0%) or number of cases of new-onset critical illness neuromyopathy (RR 1.13, 95% CI = 0.76-1.67, I 2 = 0%). Conclusion Our analysis showed that the early, short use of a continuous infusion of cisatracurium led to a statistically significant reduction in mortality in ARDS patients. The potential effects and drawbacks of the intervention were discussed.

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“…La distinción es importante porque la «mortalidad a los 90 días» (es decir, evaluar si un paciente está vivo o muerto a los 90 días después de la aleatorización, independientemente de su ubicación) es una medida de resultado más sólida que la «mortalidad hospitalaria medida a los 90 días» (es decir, evaluar la mortalidad sólo durante la estadía en el hospital dentro de los primeros 90 días de la aleatorización), ya que este último no tiene en cuenta a los pacientes que podrían haber muerto después del alta hospitalaria dentro de los primeros 90 días. 39 Del mismo modo, en el estudio de Papazian, 32 las curvas de mortalidad comienzan a separarse después de aproximadamente 18 días después de la aleatorización. Aún no se ha podido entender del todo este lapso que tarda en presentarse los efectos benéficos de los agentes bloqueadores neuromusculares y las teorías que proponen su explicación resultan controversiales.…”

Section: Investigación Previa Y Mecanismos De Acciónunclassified

Bloqueadores neuromusculares en el síndrome de insuficiencia respiratoria progresiva aguda: metaanálisis

Gómez

Alvarez

2019

Medicina Crítica

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Bloqueadores neuromusculares en el síndrome de insuficiencia respiratoria progresiva aguda: metaanálisis Neuromuscular blockers in acute respiratory distress syndrome: meta-analysis Bloqueadores neuromusculares na síndrome de insuficiência respiratória progressiva aguda: metanálise Abreviaturas: BNM = agentes bloqueadores neuromusculares. ECA = estudio controlado aleatorizado. OR = razón de momios. RR = razón de riesgo. UCI = Unidad de Cuidados Intensivos. SIRPA = síndrome de insuficiencia respiratoria progresiva aguda.Recepción: 18/09/2019. Aceptación: 02/12/2019. Este artículo puede ser consultado en versión completa en www.medigraphic.com/medicinacritica Methods: In this systematic review and meta-analysis, different databases were searched, comparing the administration of neuromuscular blocking agents versus placebo or non-treatment in patients with acute respiratory distress syndrome. Titles, abstracts and full texts of the articles were selected in duplicate by two researchers. The data for the study design, patient characteristics, interventions and results were summarized independently and in duplicate. For additional information, the authors of the selected studies were contacted by email. The GRADE guides were used to rate the quality of the evidence. We calculate the risk ratios (RR) and odds ratios (OR) with 95% confidence intervals (95% CI) for dichotomous variables, while for the continuous variables we obtained the difference in means and performed a meta-analysis of random effects. The primary outcome was the evaluation of any-cause mortality, mortality in the Intensive Care Unit, the incidence of adverse effects and the evolution of respiratory parameters. Results: Six randomized controlled studies (RCTs) were included. Compared to the placebo group or no treatment, neuromuscular blocking agents were associated with a significant reduction in any-cause mortality (603 [35.7%] of 1,691 patients versus 673 [40.5%] of 1,660 patients;] p = 0.005 I2 33%); as well as decreased mortality in the ICU ). Compared to the placebo group or no treatment, the neuromuscular blocking agents group was associated with a significant reduction in adverse events (RR 0.72 [95% CI 0.52 to 0.99], four RCTs, 3,621 patients; p = 0.15 I2 64%) and a significant improvement in the PaO 2 /FiO 2 ratio (11.02 mmHg [95% CI 5.38 to 16.66]; four RCTs, 3,637 patients; p = 0.0001 I2 24%). Conclusions: The use of neuromuscular blocking agents in adults with acute respiratory distress syndrome was associated with a significant reduction in mortality from any cause. There were fewer adverse events and a significant improvement in the PaO 2 /FiO 2 ratio in the neuromuscular blocking agents' group. Based on our results, we recommend the use of neuromuscular blocking agents for patients with moderate to severe ARDS who need mechanical ventilation. Due to the moderate to low quality of the evidence, new randomized studies with sufficient statistical power are required to confirm these findings.

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Neuromuscular blockers and ARDS: Thou shalt not breathe, move, or die!

Cited by 12 publications

References 13 publications

Early Neuromuscular Blockade in Children with Pediatric Acute Respiratory Distress Syndrome

Early Neuromuscular Blockade in Children with Pediatric Acute Respiratory Distress Syndrome

Cisatracurium for acute respiratory distress syndrome: review of current evidence

Bloqueadores neuromusculares en el síndrome de insuficiencia respiratoria progresiva aguda: metaanálisis

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