Use Of Neuromuscular Blocking Agents Research Articles

Updates in diagnosis, treatment, and prevention of anaphylaxis to neuromuscular blocking agents and their antagonists

Anaphylaxis to perioperative drugs has an insidious and rapid onset, can be life-threatening, and often results in the suspension of surgery. Neuromuscular blocking agents (NMBAs) are currently considered to be the most common cause of anaphylactic reactions among anesthetic drugs. With the increasing amount of anesthesia and surgery in the world, there are more and more NMBAs use, and the corresponding allergic risk is also increasing. With the use of NMBAs, their antagonists, such as neostigmine and sugammadex, are often used too, which have more and more allergy reports in clinical practice. Due to the complex mechanism of allergy caused by NMBAs and their antagonists, it is difficult to find out the culprit drug. The cross-reactivity between NMBAs is common, so it is often difficult to choose alternative drugs. This article summarized the epidemiology, pathological mechanisms, diagnostic methods and procedures, immediate treatment, and prevention strategies of anaphylaxis caused by these drugs.

Early short course of neuromuscular blocking agents in patients with COVID-19 ARDS: a propensity score analysis

BackgroundThe role of neuromuscular blocking agents (NMBAs) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) is not fully elucidated. Therefore, we aimed to investigate in COVID-19 patients with moderate-to-severe ARDS the impact of early use of NMBAs on 90-day mortality, through propensity score (PS) matching analysis.MethodsWe analyzed a convenience sample of patients with COVID-19 and moderate-to-severe ARDS, admitted to 244 intensive care units within the COVID-19 Critical Care Consortium, from February 1, 2020, through October 31, 2021. Patients undergoing at least 2 days and up to 3 consecutive days of NMBAs (NMBA treatment), within 48 h from commencement of IMV were compared with subjects who did not receive NMBAs or only upon commencement of IMV (control). The primary objective in the PS-matched cohort was comparison between groups in 90-day in-hospital mortality, assessed through Cox proportional hazard modeling. Secondary objectives were comparisons in the numbers of ventilator-free days (VFD) between day 1 and day 28 and between day 1 and 90 through competing risk regression.ResultsData from 1953 patients were included. After propensity score matching, 210 cases from each group were well matched. In the PS-matched cohort, mean (± SD) age was 60.3 ± 13.2 years and 296 (70.5%) were male and the most common comorbidities were hypertension (56.9%), obesity (41.1%), and diabetes (30.0%). The unadjusted hazard ratio (HR) for death at 90 days in the NMBA treatment vs control group was 1.12 (95% CI 0.79, 1.59, p = 0.534). After adjustment for smoking habit and critical therapeutic covariates, the HR was 1.07 (95% CI 0.72, 1.61, p = 0.729). At 28 days, VFD were 16 (IQR 0–25) and 25 (IQR 7–26) in the NMBA treatment and control groups, respectively (sub-hazard ratio 0.82, 95% CI 0.67, 1.00, p = 0.055). At 90 days, VFD were 77 (IQR 0–87) and 87 (IQR 0–88) (sub-hazard ratio 0.86 (95% CI 0.69, 1.07; p = 0.177).ConclusionsIn patients with COVID-19 and moderate-to-severe ARDS, short course of NMBA treatment, applied early, did not significantly improve 90-day mortality and VFD. In the absence of definitive data from clinical trials, NMBAs should be indicated cautiously in this setting.

Neuromuscular Blocking Agents and Monitoring in China: A Cross-Sectional Survey of Current Management.

BackgroundLittle is known about the recent use of neuromuscular blocking agents (NMBAs) and monitoring in China. This paper presents the results of a nationwide survey conducted to obtain information regarding the current management of NMBAs in China.MethodsA questionnaire was sent to Chinese anesthesiologists inviting them to participate in the study. The questionnaire was available through the wenjuanxing website, and the link was sent to 1,488 anesthesiologists using the Wechat mini app.ResultsThe web-based survey consisted of 28 questions, and data were collected using an online tool. Between May 19, 2021 and June 16, 2021, 637 responses were collected (response rate = 42.8%). Only 10.2% of anesthesiologists reported using neuromuscular function monitors, and 6.59% of respondents reported that they had the relevant monitors in the operating room.ConclusionAlthough PORC is a potential safety issue, the frequency of using reversal agents and monitors remains extremely low in China. Surveys such as this are important to understand the use and application customs of NMBAs in China.

Early Neuromuscular Blockade in Moderate-to-Severe Pediatric Acute Respiratory Distress Syndrome.

The use of neuromuscular blocking agents (NMBAs) in pediatric acute respiratory distress syndrome (PARDS) is common but unsupported by efficacy data. We sought to compare the outcomes between patients with moderate-to-severe PARDS receiving continuous NMBA during the first 48 hours of endotracheal intubation (early NMBA) and those without. Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial, a pediatric multicenter cluster randomized trial of sedation. Thirty-one PICUs in the United States. Children 2 weeks to 17 years receiving invasive mechanical ventilation (MV) for moderate-to-severe PARDS (i.e., oxygenation index ≥ 8 and bilateral infiltrates on chest radiograph on days 0-1 of endotracheal intubation). NMBA for the entire duration of days 1 and 2 after intubation. Among 1,182 RESTORE patients with moderate-to-severe PARDS, 196 (17%) received early NMBA for a median of 50.0% ventilator days (interquartile range, 33.3-60.7%). The propensity score model predicting the probability of receiving early NMBA included high-frequency oscillatory ventilation on days 0-2 (odds ratio [OR], 7.61; 95% CI, 4.75-12.21) and severe PARDS on days 0-1 (OR, 2.16; 95% CI, 1.50-3.12). After adjusting for risk category, early use of NMBA was associated with a longer duration of MV (hazard ratio, 0.57; 95% CI, 0.48-0.68; p < 0.0001), but not with mortality (OR, 1.62; 95% CI, 0.92-2.85; p = 0.096) compared with no early use of NMBA. Other outcomes including cognitive, functional, and physical impairment at 6 months post-PICU discharge were similar. Outcomes did not differ when comparing high versus low NMBA usage sites or when patients were stratified by baseline Pao2/Fio2 less than 150. Early NMBA use was associated with a longer duration of MV. This propensity score analysis underscores the need for a randomized controlled trial in pediatrics.

A meta-analysis of the effect of neuromuscular blocking agents on oxygenation in patients with acute respiratory distress syndrome

Objective: To evaluate the effects of neuromuscular blocking agents (NMBA) on oxygenation and respiratory conditions in patients with acute respiratory distress syndrome(ARDS). Methods: English databases such as MEDLINE, Embase and Web of Science were searched online, as well as Chinese databases such as China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database and Wanfang Database. Randomized controlled trials (RCTs) of NMBA therapy for ARDS with publication date up to May 2020 were retrieved. Literature was screened according to inclusion and exclusion criteria, and the main analysis indicators were oxygenation index. Results: A total of 5 RCTs were included, and 1 462 ARDS patients were enrolled. Compared with the control group, the ratio of partial arterial oxygen pressure to fraction of inspired (PaO2)/(FiO2) significantly improved in the intervention group after 72 hours MD=14.39, (95%CI 6.40-22.38, P=0.000 4) and 96 hours of NMBA, but there was no difference between PaO2/FiO2 at 24 and 48 hours (P>0.05).Positive end expiratory pressure (PEEP) significantly decreased at 72 hours (MD=-0.45, 95%CI -0.87--0.03, P=0.04) and 96 hours (MD=-0.82, 95%CI -1.39--0.26, P=0.004) treatment with NMBA, while there was no significant difference in PEEP between 24 and 48 hours after treatment (P>0.05). At 96 h, plateau pressure (Pplat) in the intervention group was significantly lower (MD=-1.69, 95%CI -2.64--0.75, P=0.000 4), and there was no significant difference in Pplat between 24, 48 and 72 h after treatment (P>0.05). Conclusion: The early use of NMBA within 48 hours has a delayed improvement effect on oxygenation and ventilator conditions in ARDS patients.

Factors Associated with the Underuse of Sedatives and Neuromuscular Blocking Agents for Pediatric Emergency Endotracheal Intubation in Korea.

PurposeRapid sequence intubation (RSI) using sedatives and neuromuscular blocking agents (NMBAs) is recommended for pediatric emergency endotracheal intubation (ETI), but is not frequently performed in Korea. This study aimed to verify factors associated with the underuse of RSI medications.Materials and MethodsThis multicenter retrospective study reviewed patients aged under 18 years who underwent an ETI within 24 hours of arrival at the emergency department between 2016 and 2019. Any cases of ETI during cardiopulmonary resuscitation were excluded. We investigated the characteristics of the patients, intubators, RSI medications, and outcomes. The study cases were classified into no-medication, sedative-only, and sedative-with-NMBA groups. Multivariable logistic regression analysis of RSI medication use was conducted.ResultsA total of 334 cases with a median age of 3.4 years were included in this study. Sedatives and NMBAs were used in 63.8% and 32.9%, respectively. In comparing the no-medication (n=121), sedative-only (n=103), and sedative-with-NMBA (n=110) groups, patient age (median; 1.0 year vs. 2.8 years vs. 11.3 years; p<0.001), underlying medical conditions (77.7% vs. 56.3% vs. 36.4%; p<0.001), and pediatricians as intubators (76.9% vs. 54.4% vs. 17.3%; p<0.001) were different. The factors that influenced sedatives with NMBA use were patient age [for a year increment; adjusted odds ratio (aOR), 1.182; 95% confidence interval (CI), 1.120–1.249], no underlying medical conditions (aOR, 2.109; 95% CI, 1.093–4.070), and intubators other than pediatricians (aOR, 5.123; 95% CI, 2.257–11.626).ConclusionRSI accounted for 32.9% of pediatric emergency ETI in Korea. The underuse of RSI medications is associated with younger patient age, underlying medical conditions, and pediatricians as intubators.

Neuromuscular Blocking Agent Use in Acute Respiratory Distress Syndrome: Which Variable is Important?

Background: The study of neuromuscular blocking agents (NMBAs) in the management of acute respiratory distress syndrome (ARDS) has provided conflicting results in terms of their effect on mortality. Objectives: The main purpose of this study was to evaluate mortality in ARDS patients who underwent NMBA. Methods: A retrospective secondary analysis of 4200 patients with ARDS was collected from two academic medical centers, Tehran, Iran. This study was performed to assess the impact of NMBAs use in ARDS patients with different subgroups including mild and moderate-to-severe ARDS, age more and less than 65 years, having medical turnover vs. not-having, and high acute nursing care vs. moderate to low nursing care. Results: Intensive care unit (ICU) mortality has occurred in 1169 (27.8%) participants. The mortality rate was 28.6% and 27.5% in patients with mild and moderate-to-severe ARDS, respectively. In the subjects without medical turnover, the moderate dose of NMBAs significantly reduces the mortality of patients (P=0.044). In patients who need high acute nursing care, increasing the NMBAs dose significantly reduces patients’ mortality (P=0.010). In addition, increasing the NMBAs doses significantly reduces ICU length of stay (LOS). Conclusion: This study provides evidence that the administration of different doses of NMBAs had no effect on patients’ mortality with mild or moderate-to-severe ARDS. However, higher doses of NMBAs than low doses increased the risk of mortality in patients over 80 years and can reduce the risk of death in patients less than 55 years.

Use of Neuromuscular Blocking Agents in Mechanically Ventilated Patients with COVID-19: A Propensity Score Analysis

Background: Neuromuscular blocking agents (NMBA) have been previously used in patients with acute respiratory distress syndrome (ARDS). It is unknown if NMBA are useful in COVID-19 patients who require invasive mechanical ventilation (IMV).Methods: We investigated use of NMBA in COVID-19 patients on IMV from February 1 to November 24, 2020, in 147 hospitals across 6 continents, comprising the COVID-19 Critical Care Consortium. We performed propensity score (PS) matched Cox proportional hazards analysis to appraise the impact of NMBA use for ≥2 days, continuously or discontinuously (treatment), vs. no use of NMBA or only upon commencement of IMV (control) on 28-day intensive care unit (ICU) mortality.Findings: 1548 (72%) patients received any NMBA therapy; 1165 (54%) of patients were stratified in the treatment group, with a median (IQR) time from ICU admission to commencement of NMBA therapy of 0 (0-2) days. The median (IQR) duration of NMBA therapy was 3 (2-6) days (N=1548). Upon commencement of IMV, patients who received NMBA therapy had a lower mean (±SD) PaO2/FiO2 (139±75 vs 157±93; PInterpretation: Use of NMBA is common in COVID-19 patients on IMV and associated with a 2.2-fold increase in risk of 28-day mortality. Until further randomised evidence is available, NMBA should be applied cautiously in routine clinical practice.Funding Statement: University of Queensland, Wesley Medical Research, The Prince Charles Hospital Foundation, The Health Research Board of Ireland; Biomedicine international training research programme for excellent clinician-scientists; European Union’s research and innovation programme (Horizon 2020); la Caixa Foundation. Finally, Carol Hodgson is funded by a National Health and Medical Research Council Grant.Declaration of Interests: Dr. Li Bassi received research support from Fisher & Paykel outside the submitted work. Dr. Dalton has consulting from Innovative ECMO Concepts, Abiomed and Instrumentation Labs , none which affect the current work. Dr. Brodie receives research support from ALung Technologies and he has been on the medical advisory boards for Baxter, Abiomed, Xenios and Hemovent. Dr. Fan reports personal fees from ALung Technologies, Baxter, Fresenius Medical Care, Getinge, and MC3Cardiopulmonary outside the submitted work. Dr. Laffey reports consulting fees from Baxter and Cala Medical, both outside the submitted work. Dr Nichol is supported by a health Research Board of Ireland award (CTN-2014-012). Dr. Fraser receives research support from Fisher & Paykel outside the submitted work. Remaining authors do not have any competing interest to declare. Ethics Approval Statement: Participating hospitals obtained local ethics committee approval and a waiver of informed consent was granted in all cases.De-identified patient data were collected and stored via the REDCap (Vanderbilt/NIH/NCATS UL1 TR000445 v.10.0.23) electronic data capture tool, hosted at the University of Oxford, United Kingdom and University of Queensland.

The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department

Awareness with paralysis is a devastating complication for patients receiving mechanical ventilation and risks long-term psychological morbidity. Data from the emergency department (ED) demonstrate a high rate of longer-acting neuromuscular blocking agent use, delayed analgosedation, and a lack of sedation depth monitoring. These practices are discordant with recommendations for preventing awareness with paralysis. Despite this, awareness with paralysis has not been rigorously studied in the ED population. Our objective is to assess the prevalence of awareness with paralysis in ED patients receiving mechanical ventilation. This was a single-center, prospective, observational cohort study on 383 mechanically ventilated ED patients. After extubation, we assessed patients for awareness with paralysis by using the modified Brice questionnaire. Three expert reviewers independently adjudicated awareness with paralysis. We report the prevalence of awareness with paralysis (primary outcome); the secondary outcome was perceived threat, a mediator for development of posttraumatic stress disorder. The prevalence of awareness with paralysis was 2.6% (10/383). Exposure to rocuronium at any point in the ED was significantly different between patients who experienced awareness with paralysis (70%) versus the rest of the cohort (31.4%) (unadjusted odds ratio 5.1; 95% confidence interval 1.30 to 20.1). Patients experiencing awareness with paralysis had higher mean values on the threat perception scale, denoting a higher degree of perceived threat, compared with patients who did not experience awareness with paralysis (13.4 [SD 7.7] versus 8.5 [SD 6.2]; mean difference 4.9; 95% confidence interval 0.94 to 8.8). Awareness with paralysis occurs in a significant minority of ED patients who receive mechanical ventilation. Potential associations of awareness with paralysis with ED care and increased perceived threat warrant further evaluation.

The effect of neuromuscular blocking agents uses in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials.

With the latest addition from Re-evaluation of Systemic Early Neuromuscular Blockade (ROSE) Trial result, the question of mortality benefit from neuromuscular blocking agents (NMBAs) in different studies, remained unanswered. We hypothesize that NMBAs use in moderate to severe acute respiratory distress syndrome (ARDS) does not influence intensive care unit (ICU) mortality. Pubmed, Embase and the Cochrane Library were searched for randomized controlled trials (RCTs) related to NMBAs infusion in patients with ARDS. The primary outcome was ICU mortality. Secondary outcomes were mortality at day 28 and day 90, oxygenation response to NMBA, ICU length of stay (LOS), ICU Acquired weakness (ICU-AW) and ventilator-free days (VFDs). Meta-analysis was conducted to re-evaluate the effect of NMBAs on patients with ARDS with all randomized controlled trials available. NMBAs infusion was associated with reduced ICU mortality (relative ratio [RR]: 0.69; 95% confidence-interval [CI]: 0.55-0.88; I2=0%), but not 28 days mortality (RR: 0.76; 95% CI: 0.57-1.0; I2=49%) and 90-day mortality (RR: 0.87; 95% CI: 0.70-1.08; I2=46%). NMBA use was not associated with increased risk of ICU-AW (RR: 1.21; 95% CI, 0.84 to 1.76; I2=34%). Early 48-hour NMBAs infusion in patients with moderate to severe ARDS was associated with reduced ICU mortality without improvement in oxygenation, VFDs, 28-day and 90-day mortality. It did not contribute significantly to ICU-AW. Based on these results, NMBAs infusion is recommended for moderate to severe ARDS for its short-term benefit in early phase of disease. Prolonged use of NMBAs beyond 48 hours requires further study.

Myorelaxants in ARDS patients.

Neuromuscular blocking agents (NMBAs) inhibit patient-initiated active breath and the risk of high tidal volumes and consequent high transpulmonary pressure swings, and minimize patient/ ventilator asynchrony in acute respiratory distress syndrome (ARDS). Minimization of volutrauma and ventilator-induced lung injury (VILI) results in a lower incidence of barotrauma, improved oxygenation and a decrease in circulating proinflammatory markers. Recent randomized clinical trials did not reveal harmful muscular effects during a short course of NMBAs. The use of NMBAs should be considered during the early phase of severe ARDS for patients to facilitate lung protective ventilation or prone positioning only after optimising mechanical ventilation and sedation. The use of NMBAs should be integrated in a global strategy including the reduction of tidal volume, the rational use of PEEP, prone positioning and the use of a ventilatory mode allowing spontaneous ventilation as soon as possible. Partial neuromuscular blockade should be evaluated in future trials.Electronic supplementary materialThe online version of this article (10.1007/s00134-020-06297-8) contains supplementary material, which is available to authorized users.

Early neuromuscular blocking agents for adults with acute respiratory distress syndrome: a systematic review, meta-analysis and meta-regression

ObjectiveTo determine whether neuromuscular blocking agents (NMBAs) can decrease the mortality of patients with acute respiratory distress syndrome (ARDS) and improve their clinical outcomes.DesignSystematic review, meta-analysis and meta-regression.Data sourcesPubMed, Embase,...

Neuromuscular blockade in patients with ARDS: a rapid practice guideline

The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) is to formulate an evidence-based guidance for the use of neuromuscular blocking agents (NMBA) in adults with acute respiratory distress syndrome (ARDS). The panel comprised 20 international clinical experts from 12 countries, and 2 patient representatives. We adhered to the methodology for trustworthy clinical practice guidelines and followed a strict conflict of interest policy. We convened panelists through teleconferences and web-based discussions. Guideline experts from the guidelines in intensive care, development, and evaluation Group provided methodological support. Two content experts provided input and shared their expertise with the panel but did not participate in drafting the final recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence and grade recommendations and suggestions. We used the evidence to decision framework to generate recommendations. The panel provided input on guideline implementation and monitoring, and suggested future research priorities. The overall certainty in the evidence was low. The ICM-RPG panel issued one recommendation and two suggestions regarding the use of NMBAs in adults with ARDS. Current evidence does not support the early routine use of an NMBA infusion in adults with ARDS of any severity. It favours avoiding a continuous infusion of NMBA for patients who are ventilated using a lighter sedation strategy. However, for patients who require deep sedation to facilitate lung protective ventilation or prone positioning, and require neuromuscular blockade, an infusion of an NMBA for 48 h is a reasonable option.Electronic supplementary materialThe online version of this article (10.1007/s00134-020-06227-8) contains supplementary material, which is available to authorized users.

Neuromuscular Blocking Agents for ARDS: A Systematic Review and Meta-Analysis.

Studies evaluating neuromuscular blocking agents (NMBAs) in the management of ARDS have produced inconsistent results in terms of their effect on mortality. The purpose of this systematic review and meta-analysis was to evaluate differences in mortality comparing subjects with ARDS who received NMBA to those who received placebo or usual care. We searched Ovid, MEDLINE, Embase, CINAHL, Cochrane, Scopus, and Web of Science for randomized controlled trials evaluating administration of NMBAs in subjects with ARDS. We included 6 studies (N = 1,558 subjects) from 1,814 abstracts identified by our search strategy. The use of early, continuous-infusion NMBAs reduces the risk of short-term (ie, 21-28-d) mortality (relative risk 0.71 [95% CI 0.52-0.98], P = .030, I 2 = 60%) in subjects with ARDS but does not reduce the risk of long-term (ie, 90-d) mortality (relative risk 0.81 [95% CI 0.64-1.04], P = .10, I 2 = 54%). NMBAs decreased the risk of barotrauma (relative risk 0.55 [95% CI 0.35-0.85], P = .008, I 2 = 0%) and pneumothorax (relative risk 0.46 [95% CI 0.28-0.77], P = .003, I 2 = 0%) compared to control. In subjects with ARDS, early use of NMBAs improves oxygenation, reduces the incidence of ventilator-induced lung injury, and decreases 21-28-d mortality, but it does not improve 90-d mortality. NMBAs should be considered for select patients with moderate-to-severe ARDS for short durations.

In Response.

In Response.

Association Between Target Temperature Variability and Neurologic Outcomes for Patients Receiving Targeted Temperature Management at 36°C After Cardiac Arrest: A Retrospective Cohort Study.

Maintaining strict temperature control during the maintenance phase of targeted temperature management (TTM) after cardiac arrest may be an important component of clinical care. Temperature variability outside of the goal temperature range may lessen the benefit of TTM and worsen neurologic outcomes. The purpose of this retrospective study of 186 adult patients (70.4% males, mean age 53.8 ± 15.7 years) was to investigate the relationship between body temperature variability (at least one body temperature measurement outside of 36°C ± 0.5°C) during the maintenance phase of TTM at 36°C after cardiac arrest and neurologic outcome at hospital discharge. Patients with temperature variability (n = 124 [66.7%]) did not have significantly higher odds of poor neurologic outcome compared with those with no temperature variability (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.36-2.82). Use of neuromuscular blocking agents (NMBAs) and having an initial shockable rhythm were associated with both higher odds of good neurologic outcome (shockable rhythm: OR = 10.77, 95% CI = 4.30-26.98; NMBA use: OR = 4.54, 95% CI = 1.34-15.40) and survival to hospital discharge (shockable rhythm: OR = 5.90, 95% CI = 2.65-13.13; NMBA use: OR = 3.03, 95% CI = 1.16-7.90). In this cohort of postcardiac arrest comatose survivors undergoing TTM at 36°C, having temperature variability during maintenance phase did not significantly impact neurologic outcome or survival.

Appropriate Use of Neuromuscular Blocking Agents and Reversal Drugs to Enhance Recovery Following Cardiac Surgery

To provide a brief review of the use of neuromuscular blocking agents (NMBA) in cardiac surgery, including strategies for reversal and the effects of residual blockade. While ample evidence exists in non-cardiac surgery demonstrating the potential harms of residual neuromuscular blockade (NMB), little is known about the effect on cardiac surgery patients. Few studies have examined whether residual effects are present following cardiac surgery and whether residual NMB has an impact on postoperative outcomes. In non-cardiac surgery, the incidence of residual NMB after surgery is high and associated with pulmonary complications. Anesthesiologists frequently underestimate the incidence of residual NMB in non-cardiac surgery. Objective measurement of the degree of neuromuscular recovery with acceleromyography may be challenging to apply and the monitors are not universally available. Therefore, reversal agents may be underutilized or yield incomplete reversal. As clinicians aim to decrease extubation times following cardiac surgery, the potential implication of residual NMB on perioperative outcomes increases. Research into the incidence and effect of residual NMB on outcomes following cardiac surgery is needed.

Neuromuscular-blocking agents for tracheal intubation in pediatric patients (0-12 years): A systematic review and meta-analysis.

The benefit of using neuromuscular-blocking agents to facilitate tracheal intubation in pediatric patients remains unclear due to variations in design, treatments, and results among trials. By combining the available evidence, we aimed to establish whether scientific findings are consistent and can be generalized across various populations, settings, and treatments. A systematic search for randomized controlled trials, related to the use of neuromuscular-blocking agents for tracheal intubation in American Society of Anesthesiologistsclass I-II participants (0-12years), was performed. We considered all randomized controlled trialsthat studied whether intubation conditions and hemodynamics obtained by using neuromuscular-blocking agents were equivalent to those that were achieved without neuromuscular-blocking agents. We combined the outcomes in Review Manager 5.3 (RevMan, The Cochrane Collaboration) by pairwise random-effects meta-analysis using a risk ratio(RR) for intubation conditions and mean difference for hemodynamic values (mean [95%Confidence Intervals]). Heterogeneity among trials was explored using sensitivity analyses. We identified 22 eligible randomized controlled trialswith 1651 participants. Overall, the use of a neuromuscular-blocking agent was associated with a clinically important increase in the likelihood of both excellent (RR=1.41 [1.19-1.68], I2 =76%) and acceptable (RR=1.13 [1.07-1.19], I2 =68%) intubating conditions. There is strong evidence that both unacceptable intubation conditions (RR=0.35 [0.22-0.46], I2 =23%) and failed first intubation attempts (RR=0.25 [0.14-0.42], I2 =0%) were less likely to occur when a neuromuscular-blocking agent was used compared with when it was not. Higher systolic or mean arterial pressures (mean difference=13.3 [9.1-17.5] mmHg, I2 =69%) and heart rates (mean difference=15.9 [11.0-20.8] beats/min, I2 =75%) as well as a lower incidence of arrhythmias were observed when tracheal intubation was facilitated by neuromuscular-blocking agents. The use of a neuromuscular-blocking agent during light-to-moderate depth of anesthesia can improve the quality as well as the success rate of tracheal intubation and is associated with better hemodynamic stability during induction of anesthesia.

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

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.

Validation of neuromuscular blocking agent use in acute respiratory distress syndrome: a meta-analysis of randomized trials

BackgroundWe aimed to synthesize up-to-date trials to validate the effects of neuromuscular blocking agent (NMBA) use in patients with moderate-to-severe acute respiratory distress syndrome (ARDS).MethodsSeveral databases including PubMed, EMBASE, Web of Science, and Cochrane Central Register were searched up to November 14, 2019. All randomized trials investigating the use of NMBAs in patients with moderate-to-severe ARDS and reporting mortality data were included in the meta-analysis. The primary outcome was mortality, and the secondary outcomes were clinical outcomes, including respiratory physiological parameters, incidence of barotrauma, ICU-free days, and ventilation-free days.ResultsA total of 7 trials enrolling 1598 patients were finally included in this meta-analysis. The results revealed that the use of NMBAs in moderate-to-severe ARDS could significantly decrease the mortality truncated to day 28 (RR 0.74, 95% CI 0.56 to 0.98, P = 0.03) and day 90 (RR 0.77, 95% CI 0.60 to 0.99, P = 0.04). NMBA use could significantly decrease the incidence of barotrauma (RR 0.56, 95% CI 0.36 to 0.87, P = 0.009). No significant difference was observed in ICU-free days or ventilation-free days between the NMBA and control groups.ConclusionThe use of NMBAs could significantly decrease mortality in moderate-to-severe ARDS patients and decrease the incidence of barotrauma during mechanical ventilation. However, more large-scale randomized trials are needed to further validate the effect of NMBA use in ARDS.