Neuromuscular blocking agents for acute respiratory distress syndrome: an updated meta-analysis of randomized controlled trials

Abstract

Backgrounds:The aim of this study is investigating the benefits and harms of neuromuscular blocking agents (NMBAs) in patients with acute respiratory distress syndrome (ARDS). Methods:We comprehensively searched PubMed, EMBASE, and Cochrane library for randomized controlled trials comparing NMBAs to any other comparator. We pooled data using relative risk (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes, with 95% confidence intervals. We assessed the quality of included studies using the Cochrane tool and levels of evidence using the GRADE method.Results: Finally, six RCTs (n = 1557 patients) were eligible for analysis. The results showed NMBAs use was not associated with reduced 28 days mortality (RR 0.78; 95% CI, 0.58 to 1.06; P = 0.11), 90 days mortality (RR, 0.92; 95% CI, 0.81 to 1.04; P = 0.16), and intensive care unit (ICU) mortality (RR, 0.90; 95% CI, 0.79 to 1.03; P = 0.13) in patients with ARDS. However, 21-28 days mortality was slightly lower in patients received NMBAs (RR 0.73; 95% CI, 0.54 to 0.99; P = 0.04; I 2 = 53%). Besides, NMBAs use could improve the PaO 2 /FiO 2 ratio at 48 and 72 h, decrease plateau pressure and PEEP at 72 h. Additionally, NMBAs had no significant effects on days free of ventilation at day 28 (WMD, 0.55; 95% CI, − 0.46 to 1.57; P = 0.29), days not in ICU at day 28 (WMD, 0.12; 95% CI, − 0.85 to 1.08; P = 0.82), ICU-acquired weakness (RR, 1.23; 95% CI, 0.99 to 1.93; P = 0.06). Finally, NMBAs use was associated with a lower risk of barotrauma (RR, 0.55; 95% CI, 0.35 to 0.85; P = 0.007). Conclusion:In patients with respiratory distress syndrome, NMBAs may be beneficial in reverse refractory hypoxemia and may be associated with reduced short-term mortality and incidence of barotrauma. However, there is no significant effects of NMBAs on mid-term and long-term mortality, and further studies are required.

COVID-19: Short and Long-Term Effects of Hospitalization on Muscular Weakness in the Elderly

“…For example, the use of B-adrenergic vasoactive agents such as norepinephrine to treat circulatory failure has been independently associated with ICU-acquired weakness [ 21 ]. The use of neuromuscular blocking agents during mechanical ventilation has been classically considered as a risk factor; however, it is not clear to date if they actually play a role in the development of muscular weakness [ 22 ].…”

Myorelaxants in ARDS patients

“…Including the results of ROSE, three meta-analyses showed a reduction of early (21- to 28-day) mortality [ 83 , 84 ] and late (90-day or ICU) mortality [ 83 , 85 ] in patients receiving NMBAs. Early improvement of oxygenation was also retrieved in three of these meta-analyses [ 83 , 84 , 86 ]. A lower risk of barotrauma and no effect on the occurrence of ICU-acquired weakness were constantly reported.…”

“…Recent data suggest that ARDS patients receiving cisatracurium had a lower duration of MV and ICU length of stay as compared with those receiving vecuronium [ 9 ]. Non-steroidal compounds (benzylisoquinolinium) are less associated with ICU-acquired weakness 2 TOF: train of four 3 Use with caution, BIS values might be decreased by NMBAs use 4 No increase in ICU-associated weakness from cisatracurium was demonstrated in two large RCTs [ 37 , 54 ]and in three recent meta-analysis [ 83 , 84 , 86 ]…”

“…4 No increase in ICU-associated weakness from cisatracurium was demonstrated in two large RCTs [ 37 , 54 ]and in three recent meta-analysis [ 83 , 84 , 86 ]…”

Effects of deep neuromuscular block with low-pressure pneumoperitoneum on respiratory mechanics and biotrauma in a steep Trendelenburg position

“…It may be attributed to the anti-inflammatory properties of cisatracurium rather than to a consequence of the reduction in patient-ventilator asynchrony 30 . Although a new multicentre study (ROSE trial) detected no significant decrease on long-term mortality 31 , cisatracurium may reduce biotrauma and short-term mortality 32 . In our study, all patients were deep-sedated without asynchrony and received rocuronium as an aminosteroid NMB agent.…”