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

Abstract

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.

Muscle dysfunction in the long coronavirus disease 2019 syndrome: Pathogenesis and clinical approach

“…In addition, affected patients experience limb weakness and atrophy, absence of deep tendon reflexes, sensory loss, changes in muscle contractility, and consequent functional sequelae, such as the loss of muscle strength and endurance, myalgia, fatigue, and reduced aerobic capacity and physical performance. 122 , 123 …”

Sequential use of hemadsorption using Cytosorb® and Biosky® filter- technology in a COVID-19 patient suffering from severe ARDS

“…We also did relaxation although there is con icting evidence regarding relaxation of patients with severe ARDS [16].…”

Modafinil for Wakefulness in the Critical Care Units: A Literature Review and Case Series including COVID-19 Patients at a Tertiary Care Saudi Hospital

“…Deep levels of sedation may also require prior to initiation of neuromuscular blocking agents (NMB) in moderate-to-severe acute respiratory distress syndrome (ARDS) [35]. All these factors could potentially delay the recovery of neurocognitive function and increase risks of ICU acquired weakness particularly when corticosteroids are used with aminosteroidal NMB [36]. However, clinicians should also be cognizant that COVID-19 patients are predominately presented with hyperactive delirium, and agitation due to multiple factors including direct virus invasion to CNS, prolonged mechanical ventilation, social isolation, and restricted family visitation [37].…”