Neuromuscular blockade during therapeutic hypothermia after cardiac arrest: Observational study of neurological and infectious outcomes

Lascarrou, Jean Baptiste; Gouge, Amélie Le; Dimet, Jérôme; Lachérade, Jean Claude; Martin-Lefèvre, Laurent; Fiancette, Maud; Vinatier, Isabelle; Lebert, Christine; Bachoumas, Konstantinos; Yehia, Aihem; Lagarrigue, Matthieu Henry; Colin, Gwenhaël; Reignier, Jean

doi:10.1016/j.resuscitation.2014.05.017

Cited by 46 publications

(44 citation statements)

References 40 publications

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“…NMB administration in TH not only decreases refractory shivering but also facilitates both the rapid achievement and maintenance of the target temperature. A recent report suggests that continuous intravenous NMB therapy has a beneficial effect on the survival of patients undergoing post-cardiac arrest TH [ 30 ]. However, the same study also reported that NMB therapy is associated with a non-significant increase in the frequency of early-onset pneumonia [ 30 ].…”

Section: Reviewmentioning

confidence: 99%

Neurocritical care update

Kuroda

2016

j intensive care

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This update comprises six important topics under neurocritical care that require reevaluation. For post-cardiac arrest brain injury, the evaluation of the injury and its corresponding therapy, including temperature modulation, is required. Analgosedation for target temperature management is an essential strategy to prevent shivering and minimizes endogenous stress induced by catecholamine surges. For severe traumatic brain injury, the diverse effects of therapeutic hypothermia depend on the complicated pathophysiology of the condition. Continuous electroencephalogram monitoring is an essential tool for detecting nonconvulsive status epilepticus in the intensive care unit (ICU). Neurocritical care, including advanced hemodynamic monitoring, is a fundamental approach for delayed cerebral ischemia following subarachnoid hemorrhage. We must be mindful of the high percentage of ICU patients who may develop sepsis-associated brain dysfunction.

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Section: Reviewmentioning

confidence: 99%

Neurocritical care update

Kuroda

2016

j intensive care

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“…Persistent shivering is treated according to a previously published three-step protocol [ 53 ] that has been adapted since the publication of the Bedside Shivering Assessment Score (BSAS) [ 54 , 55 ]. The goal is to obtain a BSAS ≤1.…”

Section: Methods: Participants Interventions and Outcomesmentioning

confidence: 99%

Therapeutic hypothermia after nonshockable cardiac arrest: the HYPERION multicenter, randomized, controlled, assessor-blinded, superiority trial

Lascarrou¹,

Meziani²,

Gouge³

et al. 2015

Scand J Trauma Resusc Emerg Med

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BackgroundMeta-analyses of nonrandomized studies have provided conflicting data on therapeutic hypothermia, or targeted temperature management (TTM), at 33°C in patients successfully resuscitated after nonshockable cardiac arrest. Nevertheless, the latest recommendations issued by the International Liaison Committee on Resuscitation and by the European Resuscitation Council recommend therapeutic hypothermia. New data are available on the adverse effects of therapeutic hypothermia, notably infectious complications. The risk/benefit ratio of therapeutic hypothermia after nonshockable cardiac arrest is unclear.MethodsHYPERION is a multicenter (22 French ICUs) trial with blinded outcome assessment in which 584 patients with successfully resuscitated nonshockable cardiac arrest are allocated at random to either TTM between 32.5 and 33.5°C (therapeutic hypothermia) or TTM between 36.5 and 37.5°C (therapeutic normothermia) for 24 hours. Both groups are managed with therapeutic normothermia for the next 24 hours. TTM is achieved using locally available equipment. The primary outcome is day-90 neurological status assessed by the Cerebral Performance Categories (CPC) Scale with dichotomization of the results (1 + 2 versus 3 + 4 + 5). The primary outcome is assessed by a blinded psychologist during a semi-structured telephone interview of the patient or next of kin. Secondary outcomes are day-90 mortality, hospital mortality, severe adverse events, infections, and neurocognitive performance. The planned sample size of 584 patients will enable us to detect a 9% absolute difference in day-90 neurological status with 80% power, assuming a 14% event rate in the control group and a two-sided Type 1 error rate of 4.9%. Two interim analyses will be performed, after inclusion of 200 and 400 patients, respectively.DiscussionThe HYPERION trial is a multicenter, randomized, controlled, assessor-blinded, superiority trial that may provide an answer to an issue of everyday relevance, namely, whether TTM is beneficial in comatose patients resuscitated after nonshockable cardiac arrest. Furthermore, it will provide new data on the tolerance and adverse events (especially infectious complications) of TTM at 32.5-33.5°C.Trial registrationClinicalTrials.gov: NCT01994772.

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“…27 Likewise, in patients with cardiac arrest, continuous infusion of neuromuscular blocking drugs during therapeutic hypothermia was associated with more frequent early-onset pneumonia. 28 A recent trial of neuromuscular blockade for ARDS did not report increased risk of ventilator-associated pneumonia with the use of cisatracurium. 8 In theory, corticosteroids may favor the recruitment of T helper (Th) type 2 cells rather than Th1 cells.…”

Section: Secondary Infectionsmentioning

confidence: 99%

What Is the Evidence for Harm of Neuromuscular Blockade and Corticosteroid Use in the Intensive Care Unit?

Annane

2016

Semin Respir Crit Care Med

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Neuromuscular blocking agents and corticosteroids are widely used in medicine and in particular in the intensive care unit (ICU). Neuromuscular blockade is commonly used to ease tracheal intubation, to optimize mechanical ventilation and oxygenation in acute respiratory disorders such as status asthmaticus and acute respiratory distress syndrome (ARDS), to prevent shivering during therapeutic hypothermia, and also in patients with elevated intracranial pressure. In the ICU, patients with sepsis, ARDS, community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, severe asthma, or trauma may receive corticosteroids. It is not rare that ICU patients receive concomitantly neuromuscular blocking drugs and corticosteroids. Among the various serious adverse reactions to these drugs, secondary infection and ICU-acquired weakness may place a burden to the health-care system by resulting in substantial cost and long-term morbidity. Both superinfections and ICU-acquired paresis are more likely when high doses of fluorinated corticosteroids are combined with prolonged treatment with a long-acting non-depolarizing neuromuscular blocker. Modern ICU practices favor lower dose of corticosteroids and very short course of short-acting curare for the management of sepsis or ARDS. Recent trials provided no evidence for increased risk of secondary infections or critical illness neuromyopathy in patients with sepsis or ARDS with the use of corticosteroids or neuromuscular blockers.

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Neuromuscular blockade during therapeutic hypothermia after cardiac arrest: Observational study of neurological and infectious outcomes

Abstract: Continuous intravenous NMB during TH after cardiac arrest has potential owns effects on ICU survival with a trend increase in the frequency of early-onset pneumonia. Randomised controlled trials are needed to define the role for NMB among treatments for TH-induced shivering.

Cited by 46 publications

References 40 publications

Neurocritical care update

Neurocritical care update

Therapeutic hypothermia after nonshockable cardiac arrest: the HYPERION multicenter, randomized, controlled, assessor-blinded, superiority trial

What Is the Evidence for Harm of Neuromuscular Blockade and Corticosteroid Use in the Intensive Care Unit?

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