Abstract
BackgroundNeuromuscular blocking agent (NMBA) has been proposed by medical guidelines for early severe acute respiratory distress syndrome (ARDS) because of its survival benefits. However, new studies have provided evidence contradicting these results.MethodA search was performed of the Pubmed, Scopus, Clinicaltrials.gov, and Virtual Health Library databases for randomized controlled trials (RCT) evaluating 28-day mortality in ARDS patients treated with NMBA within 48 h. An English language restriction was applied. Relevant data were extracted and pooled into risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) using random-effect model. Sensitivity and meta-regression analysis were performed.ResultsFrom 2675 studies, we included five RCTs in the analysis, for a total of 1461 patients with a mean PaO2/FIO2 of 104 ± 35 mmHg. The cisatracurium group had the same risk of death at 28 days (RR, 0.90; 95% CI, 0.78–1.03; I2 = 50%, p = 0.12) and 90 days (RR, 0.81; 95% CI, 0.62–1.06; I2 = 56%, p = 0.06) as the control group (no cisatracurium). The secondary outcomes of mechanical ventilation duration and ventilator-free days were not different between the two groups. Cisatracurium had a significantly lower risk of barotrauma than the control group with no difference in intensive care unit (ICU)–induced weakness. The PaO2/FIO2 ratio was higher in the cisatracurium group but not until 48 h. Meta-regression analysis of the baseline PaO2/FIO2 ratio, positive end-expiratory pressure (PEEP) revealed no heterogeneity. Subgroup analysis excluding the trial using high PEEP and light sedation strategy yielded an improvement in all mortality outcomes.ConclusionNMBA improves oxygenation only after 48 h in moderate, severe ARDS patients and has a lower barotrauma risk without affecting ICU weakness. However, NMBA does not reduce ventilator-free days, duration of mechanical ventilation or, most importantly, the mortality risk regardless of the severity of ARDS.
Highlights
Neuromuscular blocking agent (NMBA) has been proposed by medical guidelines for early severe acute respiratory distress syndrome (ARDS) because of its survival benefits
The cisatracurium group had the same risk of death at 28 days (RR, 0.90; 95% confidence intervals (CI), 0.78–1.03; I2 = 50%, p = 0.12) and 90 days (RR, 0.81; 95% CI, 0.62–1.06; I2 = 56%, p = 0.06) as the control group
The cisatracurium group had the same risk of death at 28 days (RR, 0.90; 95% CI, 0.78–1.03; I2 = 50%, p = 0.12) and 90 days (RR, 0.81; 95% CI, 0.62–1.06; I2= 56%, p = 0.06) but had a significantly lower intensive care unit (ICU) mortality compared to the control group (RR, 0.72; 95% CI, 0.57–0.91; I2 = 0%; p = 0.007)
Summary
Neuromuscular blocking agent (NMBA) has been proposed by medical guidelines for early severe acute respiratory distress syndrome (ARDS) because of its survival benefits. The largest randomized controlled trial on NMBA in early ARDS patients was published to reassess the effect of an early, short-term continuous infusion of cisatracurium (ROSE trial), and no survival benefit was found [19]. This result was different from major studies published previously on the same topic [9,10,11]
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