ARDS · Neuromuscular blockade
Neuromuscular blockers in early acute respiratory distress syndrome
| Design | Multicentre, double-blind, placebo-controlled randomised trial |
|---|---|
| Treatment | Cisatracurium infusion for 48 hours, started within 48 hours of ARDS onset |
| Control | Placebo |
| Population | 340 patients with severe ARDS |
| Follow-up | 90 days |
| Primary endpoint | 90-day mortality, adjusted |
| Result | Adjusted hazard ratio for death at 90 days 0.68 (95% CI 0.48 to 0.98, p=0.04). Crude 90-day mortality 31.6% with cisatracurium versus 40.7% with placebo (p=0.08). Mortality at 28 days 23.7% versus a higher placebo rate. Time off the ventilator increased without more muscle weakness. |
| Secondary endpoints | Ventilator-free days, ICU-acquired weakness, barotrauma |
In patients with severe ARDS, early administration of a neuromuscular blocking agent improved the adjusted 90-day survival and increased the time off the ventilator without increasing muscle weakness.
The trial authors, in the published abstract
Note the gap between the adjusted result (p=0.04) and the crude one (p=0.08) — the benefit rests on covariate adjustment. ROSE later tested the same intervention against lighter sedation and found nothing, which is the better guide to practice today.
Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010 Sep 16;363(12):1107-16.