Neuromuscular blockers in the acute respiratory distress syndrome: A meta-analysis

Abstract

Background The effects of neuromuscular blocking agents (NMBAs) on adult patients with acute respiratory distress syndrome (ARDS) remain unclear. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate its effect on mortality. Methods We searched the Cochrane (Central) database, Medline, Embase, the Chinese Biomedical Literature Database (SinoMed), WanFang data and ClinicalTrials from inception to June 2019, with language restriction to English and Chinese. We included published RCTs and eligible clinical trials from ClinicalTrials.gov that compared NMBAs with placebo or usual treatment in adults with ARDS. We pooled data using random-effects models. The primary outcome was mortality. The secondary outcomes were the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO 2 /FIO 2), total positive end expiratory pressure (PEEP), plateau pressure (Pplat), days free of ventilator at day 28, barotrauma and ICU-acquired weakness. Results We included 6 RCTs (n = 1557). Compared with placebo or usual treatment, NMBAs were associated with lower 21 to 28-day mortality (RR 0.72, 95% CI 0.53-0.97, I2 = 59%). NMBAs significantly improved oxygenation (Pao2:Fio2 ratios) at 48 hours (MD 27.26 mm Hg, 95% CI 1.67, 52.84, I2 = 92%) and reduced the incidence of barotrauma (RR 0.55, 95% CI 0.35, 0.85, I2 = 0). However, NMBAs had no effect on oxygenation (Pao2:Fio2 ratios) (MD 18.41 mm Hg, 95% CI-0.33, 37.14, I2 = 72%) at 24 hours. We also found NMBAs did not affect total PEEP, plateau pressure, days free of ventilation at day 28 and ICU-acquired weakness.

A physiological approach to understand the role of respiratory effort in the progression of lung injury in SARS-CoV-2 infection

“…P-SILI during MV can occur in situations where high respiratory drive cannot be controlled. A short course of deep sedation and neuromuscular blocker (NMB), with daily assessment of discontinuation (NMB-holiday) is recommended [82,83]. Weaning in ARF-COVID-19 also needs a special consideration.…”

Myorelaxants in ARDS patients

“…Conversely, NMBAs (if sedation alone fails to improve respiratory status) integrated into an overall strategy including a reasoned use of PEEP, prone positioning and the rapid implementation of spontaneous breathing might improve the prognosis [ 37 , 54 ]. Including the results of ROSE, three meta-analyses showed a reduction of early (21- to 28-day) mortality [ 83 , 84 ] and late (90-day or ICU) mortality [ 83 , 85 ] in patients receiving NMBAs. Early improvement of oxygenation was also retrieved in three of these meta-analyses [ 83 , 84 , 86 ].…”

“…Including the results of ROSE, three meta-analyses showed a reduction of early (21- to 28-day) mortality [ 83 , 84 ] and late (90-day or ICU) mortality [ 83 , 85 ] in patients receiving NMBAs. Early improvement of oxygenation was also retrieved in three of these meta-analyses [ 83 , 84 , 86 ]. A lower risk of barotrauma and no effect on the occurrence of ICU-acquired weakness were constantly reported.…”

“…Recent data suggest that ARDS patients receiving cisatracurium had a lower duration of MV and ICU length of stay as compared with those receiving vecuronium [ 9 ]. Non-steroidal compounds (benzylisoquinolinium) are less associated with ICU-acquired weakness 2 TOF: train of four 3 Use with caution, BIS values might be decreased by NMBAs use 4 No increase in ICU-associated weakness from cisatracurium was demonstrated in two large RCTs [ 37 , 54 ]and in three recent meta-analysis [ 83 , 84 , 86 ]…”

“…4 No increase in ICU-associated weakness from cisatracurium was demonstrated in two large RCTs [ 37 , 54 ]and in three recent meta-analysis [ 83 , 84 , 86 ]…”