The effect of neuromuscular blockade on oxygen consumption in sedated and mechanically ventilated pediatric patients after cardiac surgery

Lemson, Joris; Driessen, J. J.; Hoeven, Johannes G. van der

doi:10.1007/s00134-008-1252-z

Cited by 16 publications

(9 citation statements)

References 20 publications

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“…Vernon et al observed a modest reduction in O 2 of 8.7 ± 1.7% and that in energy expenditure of 10.3 ± 1.8% of pre-NMB values in 20 mechanically ventilated children of whom five had acute respiratory failure [41]. Lemson et al were unable to find any reduction in O 2 in pediatric cardiac surgery patients [42]. We observed a significant improvement in PaO 2 /FiO 2 in the presence of a fixed FiO 2 in patients with moderate or severe PARDS that could not be explained by an increase in EELV.…”

Section: Discussionmentioning

confidence: 99%

Short-term effects of neuromuscular blockade on global and regional lung mechanics, oxygenation and ventilation in pediatric acute hypoxemic respiratory failure

Wilsterman

Jager

Blokpoel

et al. 2016

Ann. Intensive Care

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BackgroundNeuromuscular blockade (NMB) has been shown to improve outcome in acute respiratory distress syndrome (ARDS) in adults, challenging maintaining spontaneous breathing when there is severe lung injury. We tested in a prospective physiological study the hypothesis that continuous administration of NMB agents in mechanically ventilated children with severe acute hypoxemic respiratory failure (AHRF) improves the oxygenation index without a redistribution of tidal volume V T toward non-dependent lung zones.MethodsOxygenation index, PaO2/FiO2 ratio, lung mechanics (plateau pressure, mean airway pressure, respiratory system compliance and resistance), hemodynamics (heart rate, central venous and arterial blood pressures), oxygenation [oxygenation index (OI), PaO2/FiO2 and SpO2/FiO2], ventilation (physiological dead space-to-V T ratio) and electrical impedance tomography measured changes in end-expiratory lung volume (EELV), and V T distribution was measured before and 15 min after the start of continuous infusion of rocuronium 1 mg/kg. Patients were ventilated in a time-cycled, pressure-limited mode with pre-set V T. All ventilator settings were not changed during the study.ResultsTwenty-two patients were studied (N = 18 met the criteria for pediatric ARDS). Median age (25–75 interquartile range) was 15 (7.8–77.5) weeks. Pulmonary pathology was present in 77.3%. The median lung injury score was 9 (8–10). The overall median CoV and regional lung filling characteristics were not affected by NMB, indicating no ventilation shift toward the non-dependent lung zones. Regional analysis showed a homogeneous time course of lung inflation during inspiration, indicating no tendency to atelectasis after the introduction of NMB. NMB decreased the mean airway pressure (p = 0.039) and OI (p = 0.039) in all patients. There were no significant changes in lung mechanics, hemodynamics and EELV. Subgroup analysis showed that OI decreased (p = 0.01) and PaO2/FiO2 increased (p = 0.02) in patients with moderate or severe PARDS.ConclusionsNMB resulted in an improved oxygenation index in pediatric patients with AHRF. Distribution of V T and regional lung filling characteristics were not affected.

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Section: Discussionmentioning

confidence: 99%

Short-term effects of neuromuscular blockade on global and regional lung mechanics, oxygenation and ventilation in pediatric acute hypoxemic respiratory failure

Wilsterman

Jager

Blokpoel

et al. 2016

Ann. Intensive Care

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“…Conversely, Bishop showed that paralysis with pancuronium did not change PaO2 or cardiac output [36]. Other more recent studies have also failed to show benefits in arterial oxygenation [37].…”

Section: Potential Benefits Of Nmbamentioning

confidence: 97%

Neuromuscular Blockade in the Optimal Management of Mechanical Ventilation of Patients with Respiratory Distress

Freebairn¹,

McHugh

2010

CRMR

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Mechanical ventilation is an integral component in the management of patients with acute respiratory failure. The role of neuromuscular junction blocking agents (NMBA) in facilitating mechanical ventilation in intensive care remains controversial. NMBA have been variously advocated to decrease oxygen consumption through reduction of the work of breathing, ablation of shivering and reduction of metabolic rates, as well as to increase oxygen delivery through improved ventilation. Additional attributed benefits include the reduced potential for barotrauma, enhanced ventilatorpatient synchrony, and an ability to reduce the inspired fraction of oxygen. Despite all of these putative benefits, there remains scant high-grade evidence to guide rationale use of NMBA in the critically ill patient. Many Clinical Practice Guidelines recommend that NMBA be avoided due to the associated risk of prolonged neuromuscular weakness. Other adverse effects associated with NMBA use include the consequences of undetected circuit disconnection, reduced neurological signs, risk of awareness and recall in inadequately sedated patients, increased post-traumatic stress disorder, and reduction in supported spontaneous breathing and coughing.Optimal paralysis depth remains empiric and is often poorly controlled or monitored in intensive care. Nonetheless prudent NMBA does not appear to prolong ventilation. Refractory hypoxemia almost invariably leads to the use of NMBA. Intriguingly, systematic use of NMBA for 48 hours appears to have beneficial long-term effects in patients with severe ARDS. Rather than simply targeting short term gain in oxygenation and lung mechanics, this benefit may justify a 2-day period of NMBA use in severe ARDS.

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“…They are recommended if effective mechanical ventilation cannot be achieved despite profound sedation [e.g., ARDS (77), severe asthma (25, 79)]. They are often used in case of severe cardio-vascular instability, but their benefit may be limited because only modest decrease in energy consumption is achieved compared to profound sedation (80, 81). Other common uses are refractory pulmonary and intracranial hypertension (82).…”

Section: Commonly Used Agentsmentioning

confidence: 99%

Sedation in Critically Ill Children with Respiratory Failure

Vet¹,

Kleiber²,

Ista³

et al. 2016

Front. Pediatr.

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This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.

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The effect of neuromuscular blockade on oxygen consumption in sedated and mechanically ventilated pediatric patients after cardiac surgery

Cited by 16 publications

References 20 publications

Short-term effects of neuromuscular blockade on global and regional lung mechanics, oxygenation and ventilation in pediatric acute hypoxemic respiratory failure

Short-term effects of neuromuscular blockade on global and regional lung mechanics, oxygenation and ventilation in pediatric acute hypoxemic respiratory failure

Neuromuscular Blockade in the Optimal Management of Mechanical Ventilation of Patients with Respiratory Distress

Sedation in Critically Ill Children with Respiratory Failure

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