Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient: 2016 update—executive summary

Murray, Michael J.; DeBlock, Heidi F.; Erstad, Brian L.; Gray, Anthony W.; Jacobi, Judith; Jordan, Ché J.; McGee, William T.; McManus, Claire; Meade, Maureen O.; Nix, Sean A.; Patterson, Andrew J.; Sands, Karen; Pino, Richard M.; Tescher, Ann N.; Arbour, Richard; Rochwerg, Bram; Murray, Catherine Friederich; Mehta, Sangeeta

doi:10.2146/ajhp160803

Cited by 22 publications

(18 citation statements)

References 42 publications

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“…Clinical judgment was not able to diagnose under- or over-paralysis compared to TOF monitoring. The most current recommendations consider associating TOF monitoring and clinical judgment [ 11 ].…”

Section: Discussionmentioning

confidence: 99%

“…A current study, trying to revaluate the role of cisatracurium during ARDS (ROSE study, NCT02509078), uses the same posology. Recent guidelines [ 11 ] recommend the use of continuous NMBA infusion in ARDS patients with a PaO 2 /FiO 2 ratio under 150 but do not suggest any dosage. In a study by Bouju et al [ 12 ], the cisatracurium dosage used was much lower than in the ACURASYS study.…”

Section: Discussionmentioning

confidence: 99%

“…Important discrepancies have been demonstrated for muscle paralysis evaluation between ulnar and facial sites [ 12 ]. French recommendations have advised to preferentially use the facial site [ 27 ], whereas recent guidelines from the Society of Critical Medicine did not prioritize one site over the other [ 11 ]. Using the ulnar site, we chose to aim for a TOF goal of 0 twitches to ensure deep muscle paralysis and especially a diaphragmatic relaxation.…”

Section: Discussionmentioning

confidence: 99%

“…Recent guidelines recommend the use of NMBAs in ARDS patients who have a PaO 2 /FiO 2 ratio under 150 [ 11 ]. However, an accurate dosage of cisatracurium is currently not recommended.…”

Section: Introductionmentioning

confidence: 99%

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How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study

Hraiech

Forel

Guervilly

et al. 2017

Ann. Intensive Care

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BackgroundNeuromuscular blocking agents (NMBAs) have been shown to improve the outcome of the most severely hypoxemic, acute respiratory distress syndrome (ARDS) patients. However, the recommended dosage as well as the necessity of monitoring the neuromuscular block is unknown. We aimed to evaluate the efficiency of a nurse-directed protocol of NMBA administration based on a train-of-four (TOF) assessment to ensure a profound neuromuscular block and decrease cisatracurium consumption compared to an elevated and constant dose regimen. A prospective open labeled study was conducted in two medical intensive care units of two French university hospitals. Consecutive ARDS patients with a PaO2/FiO2 ratio less than 120 with a PEEP ≥5 cm H2O were included. Cisatracurium administration was driven by the nurses according to an algorithm based on TOF monitoring. The primary endpoint was cisatracurium consumption. The secondary endpoints included the quality of the neuromuscular block, the occurrence of adverse events, and the evolution of ventilatory and blood gas parameters.ResultsThirty patients were included. NMBAs were used for 54 ± 30 h. According to this new algorithm, the initial dosage of cisatracurium was 11.8 ± 2 mg/h, and the final dosage was 14 ± 4 mg/h, which was significantly lower than in the ACURASYS study protocol (37.5 mg/h with a constant infusion rate (p < 0.001). The overall cisatracurium dose used was 700 ± 470 mg in comparison with 2040 ± 1119 mg for patients had received the ACURASYS dosage for the same period (p < 0.001). A profound neuromuscular block (TOF = 0, twitches at the ulnar site) was obtained from the first hour in 70% of patients. Modification of the cisatracurium dosage was not performed from the beginning to the end of the study in 60% of patients. Patient–ventilator asynchronies occurred in 4 patients.ConclusionA nurse-driven protocol based on TOF monitoring for NMBA administration in ARDS patients was able to decrease cisatracurium consumption without significantly affecting the quality of the neuromuscular block.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…Recent guidelines recommend the use of NMBAs in ARDS patients who have a PaO 2 /FiO 2 ratio under 150 [ 11 ]. However, an accurate dosage of cisatracurium is currently not recommended.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study

Hraiech

Forel

Guervilly

et al. 2017

Ann. Intensive Care

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“…In a large observational study, the mortality rate of moderate to severe ARDS was up to 40% [4]. Neuromuscular blocking agents (NMBA) have been proposed during the early course of moderate to severe ARDS especially in those with PaO 2 /FIO 2 < 120 mmHg to improve oxygenation and reduce patient-ventilator dyssynchrony [6][7][8]. NMBA facilitates oxygenation in various studies [9][10][11] by various mechanisms, including reducing ventilator-induced lung injuries and inhibiting inflammatory cytokines [12,13].…”

Section: Introductionmentioning

confidence: 99%

Neuromuscular blockade in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials

Patolia

Guervilly

2020

j intensive care

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Background: Neuromuscular 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. Method: A 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 metaregression analysis were performed. Results: From 2675 studies, we included five RCTs in the analysis, for a total of 1461 patients with a mean PaO 2 / FIO 2 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; I 2 = 50%, p = 0.12) and 90 days (RR, 0.81; 95% CI, 0.62-1.06; I 2 = 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 PaO 2 /FIO 2 ratio was higher in the cisatracurium group but not until 48 h. Meta-regression analysis of the baseline PaO 2 /FIO 2 ratio, positive endexpiratory pressure (PEEP) revealed no heterogeneity. Subgroup analysis excluding the trial using high PEEP and light sedation strategy yielded an improvement in all mortality outcomes. Conclusion: NMBA 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.

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Neuromuscular Blocking Agents

Bignami

Saglietti

2017

Critical Care Sedation

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Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient: 2016 update—executive summary

Cited by 22 publications

References 42 publications

How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study

How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study

Neuromuscular blockade in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials

Neuromuscular Blocking Agents

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