Sedation and neuromuscular blocking agents in acute respiratory distress syndrome

Bourenne, Jérémy; Hraiech, Sami; Roch, Antoine; Gainnier, Marc; Papazian, Laurent; Forel, Jean-Marie

doi:10.21037/atm.2017.07.19

Cited by 58 publications

(48 citation statements)

References 89 publications

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“…[19][20][21][22] Studies also suggest decreased incidence of barotrauma and ventilator induced lung injury with the use of NMBAs. 8,21 However, all these authors had studied adult patients. Mortality in our study control group was 46.7% (14/30).…”

Section: Discussionmentioning

confidence: 99%

“…6 Clinical practice in PARDS is mostly extrapolated from findings in adult studies and further research in stratification of management in PARDS is urgently required. 7 A review done in 2017 8 suggests that neuromuscular blocking agents (NMBAs) are used in 25 to 45% of ARDS patients for a mean period of 1 AE 2 days. However, role of neuromuscular blockade in the management of ARDS is still controversial.…”

Section: Introductionmentioning

confidence: 99%

“…However, role of neuromuscular blockade in the management of ARDS is still controversial. 8 Earlier studies 9 found that use of neuromuscular blockade is associated with longer duration of mechanical ventilation, weaning time, intensive care unit (ICU) stay, and higher mortality. However, majority of these studies, involving the use of NMBAs, have been done in adult patients.…”

Section: Introductionmentioning

confidence: 99%

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Early Neuromuscular Blockade in Children with Pediatric Acute Respiratory Distress Syndrome

Chandra

Goel

Dawra

2020

J Pediatr Intensive Care

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Pediatric acute respiratory distress syndrome (PARDS) is a challenging problem with high mortality. Role of neuromuscular blockade in the management of ARDS to date has been controversial, and this study was done to study the role of neuromuscular blockade in children having PARDS and development of associated complications, if any. This was a prospective, case–control study conducted in the pediatric intensive care unit (PICU) of a tertiary care teaching hospital, over a period of 24 months. Patients of age 1 to 18 years who presented with or developed PARDS during their course of hospitalization were included after written informed consent was obtained from their parents and/or guardians. Patients with PARDS requiring invasive mechanical ventilation were partitioned into a case group and a control group. Case group patients were sedated and paralyzed using midazolam (1 µg/kg/min) and vecuronium (1 µg/kg/min), respectively, along with institution of definitive management. Control group patients were given definitive and supportive therapy, but no neuromuscular blocking agents (NMBAs). All patients were followed up for signs and symptoms of myopathy or neuropathy during the entire duration of hospital stay and up to 3 months after discharge. During the study period, 613 patients were admitted to the PICU of which 91 patients qualified as having PARDS. Sepsis was the main etiology in 67 of the 91 patients (73.6%) with PARDS. Fifty-nine patients were included in the study, of which 29 patients were included in the case group and 30 patients were included in the control group. Among the 29 case group patients, 25 patients (86.2%) were successfully extubated. Four patients from the case group expired, while 14 out of 30 control group patients (46.7%) expired. Hypotension was present in 26 case group patients (89.6%), of which all showed resolution within 48 hours of definitive treatment. The mean time to resolution of hypotension was 41.6 hours (standard deviation [SD]: 5.759; range: 24–48) for case group patients, significantly lower (p < 0.0001) than the mean time to resolution of 103 hours (SD: 18.995; range: 90–126) for the 10 control group patients with hypotension that survived. Mean oxygenation index (OI) following 48 hours of vecuronium therapy was significantly lower (p < 0.0001; 95% confidence interval: 5.9129–9.9671) than mean OI at admission for case group patients. None of the patients receiving vecuronium exhibited neuromuscular deficit during their hospital stay, at time of discharge, or at follow-up evaluation up to 3 months after discharge. In this study, pediatric cases diagnosed with PARDS and managed with mechanical ventilation and vecuronium therapy had improved mean OI following 48 hours of NMBA therapy and a lower mortality when compared with matched control group patients. Incidence of NMBA-related weakness was not commonly observed in these patients.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Early Neuromuscular Blockade in Children with Pediatric Acute Respiratory Distress Syndrome

Chandra

Goel

Dawra

2020

J Pediatr Intensive Care

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“…Whether spontaneous respiration in ARDS is helpful or harmful remains an area of debate [8]. Clinical studies confirmed that sedation inhibits the driving of the respiratory center and reduces the amplitude of spontaneous respiration, especially for early moderate to severe ARDS, deep sedation and even muscle relaxation can greatly improve the prognosis of patients and reduce the incidence of VILI [9,10]. However, for mild ARDS or convalescent ARDS, it is recommended to keep spontaneous respiration, which may be more conducive to the recovery of the disease.…”

Section: Introductionmentioning

confidence: 99%

Effect of Deep Sedation on Mechanical Power in Moderate to Severe Acute Respiratory Distress Syndrome: A Prospective Self‐Control Study

Xie

Cao

Qian

et al. 2020

BioMed Research International

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Mechanical power (MP) is a parameter for assessing ventilator-induced lung injury (VILI) in patients with acute respiratory distress syndrome (ARDS). Deep sedation inhibits the respiratory center and reduces the excessive spontaneous breathing in ARDS patients, thereby reducing transpulmonary pressure (Ptp) and lung injury. However, the effect of sedation on MP in ARDS patients is not yet clear. Therefore, the purpose of this study was to investigate the effect of deep sedation on MP in ARDS patients. Patients with moderate to severe ARDS who required mechanical ventilation were considered. Different degrees of sedation were performed on patients in three stages after 24 hours of mechanical ventilation. The three stages are as follows: stage 1 (H+3): 0 to 3 hours of sedation; patients’ Ramsay score was 2-3 to obtain mild sedation; stage 2 (H+6): 4 to 6 hours of sedation; the sedation depth was adjusted to 5-6 points; and stage 3 (H+9): 7 to 9 hours of sedation; the sedation depth was adjusted to 2-3 points. Under deep sedation (H+6), MP, respiratory rate (RR), and Ptp were significantly lower than the ones in the patients under mild sedation (H+3) (all P<0.01) although PaO2/FiO2 (P/F) and static lung compliance (Cst) were significantly higher (both P<0.01). However, no significant difference in the above parameters was observed between H+3 and H+9. Correlation analysis showed that ΔMP was significantly and positively correlated with ΔRR and ΔPtp (both P<0.001), while no correlation was observed neither between ΔMP and ΔCst nor between ΔMP and ΔP/F. The 28-day Kaplan-Meier survival curve showed the occurrence of 19 deaths, and the overall survival rate was 63.46%. The survival rate was 53.12% in the high-MP (HMP) group and 80.95 in the low-MP (LMP) group (P<0.05). In conclusion, deep sedation significantly reduced MP in patients with moderate to severe ARDS, thereby reducing the occurrence of VILI. In addition, MP monitoring in deep sedation predicted the 28-day survival of patients with moderate to severe ARDS.

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“…Las primeras publicaciones sobre BNM fueron reportes de casos que obtuvieron mejoría en la relación PaO 2 / FiO 2 . [13][14][15][16][17] Hasta donde es de nuestro conocimiento, se han publicado tres metaanálisis sobre el tema. [18][19][20] Sin embargo, en ninguno de los estudios previos se cita la evidencia más reciente.…”

Section: Introductionunclassified

Bloqueadores neuromusculares en el síndrome de insuficiencia respiratoria progresiva aguda: metaanálisis

Gómez

Alvarez

2019

Medicina Crítica

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Bloqueadores neuromusculares en el síndrome de insuficiencia respiratoria progresiva aguda: metaanálisis Neuromuscular blockers in acute respiratory distress syndrome: meta-analysis Bloqueadores neuromusculares na síndrome de insuficiência respiratória progressiva aguda: metanálise Abreviaturas: BNM = agentes bloqueadores neuromusculares. ECA = estudio controlado aleatorizado. OR = razón de momios. RR = razón de riesgo. UCI = Unidad de Cuidados Intensivos. SIRPA = síndrome de insuficiencia respiratoria progresiva aguda.Recepción: 18/09/2019. Aceptación: 02/12/2019. Este artículo puede ser consultado en versión completa en www.medigraphic.com/medicinacritica Methods: In this systematic review and meta-analysis, different databases were searched, comparing the administration of neuromuscular blocking agents versus placebo or non-treatment in patients with acute respiratory distress syndrome. Titles, abstracts and full texts of the articles were selected in duplicate by two researchers. The data for the study design, patient characteristics, interventions and results were summarized independently and in duplicate. For additional information, the authors of the selected studies were contacted by email. The GRADE guides were used to rate the quality of the evidence. We calculate the risk ratios (RR) and odds ratios (OR) with 95% confidence intervals (95% CI) for dichotomous variables, while for the continuous variables we obtained the difference in means and performed a meta-analysis of random effects. The primary outcome was the evaluation of any-cause mortality, mortality in the Intensive Care Unit, the incidence of adverse effects and the evolution of respiratory parameters. Results: Six randomized controlled studies (RCTs) were included. Compared to the placebo group or no treatment, neuromuscular blocking agents were associated with a significant reduction in any-cause mortality (603 [35.7%] of 1,691 patients versus 673 [40.5%] of 1,660 patients;] p = 0.005 I2 33%); as well as decreased mortality in the ICU ). Compared to the placebo group or no treatment, the neuromuscular blocking agents group was associated with a significant reduction in adverse events (RR 0.72 [95% CI 0.52 to 0.99], four RCTs, 3,621 patients; p = 0.15 I2 64%) and a significant improvement in the PaO 2 /FiO 2 ratio (11.02 mmHg [95% CI 5.38 to 16.66]; four RCTs, 3,637 patients; p = 0.0001 I2 24%). Conclusions: The use of neuromuscular blocking agents in adults with acute respiratory distress syndrome was associated with a significant reduction in mortality from any cause. There were fewer adverse events and a significant improvement in the PaO 2 /FiO 2 ratio in the neuromuscular blocking agents' group. Based on our results, we recommend the use of neuromuscular blocking agents for patients with moderate to severe ARDS who need mechanical ventilation. Due to the moderate to low quality of the evidence, new randomized studies with sufficient statistical power are required to confirm these findings.

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Sedation and neuromuscular blocking agents in acute respiratory distress syndrome

Cited by 58 publications

References 89 publications

Early Neuromuscular Blockade in Children with Pediatric Acute Respiratory Distress Syndrome

Early Neuromuscular Blockade in Children with Pediatric Acute Respiratory Distress Syndrome

Effect of Deep Sedation on Mechanical Power in Moderate to Severe Acute Respiratory Distress Syndrome: A Prospective Self‐Control Study

Bloqueadores neuromusculares en el síndrome de insuficiencia respiratoria progresiva aguda: metaanálisis

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