Benefits to neuromuscular blockers in early ARDS

Daily POEMs

Published: 2010-11-29 © 2010 John Wiley & Sons, Inc.

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Clinical question
Does the use of the neuromuscular blocker, cisatracurium, reduce mortality in patients with early acute respiratory distress?

Bottom line
Cisatracurium, a neuromuscular blocker, when used in patients with early and severe acute respiratory distress (ARDS), results in decreased mortality and more ventilator-free days without increasing the incidence of intensive care unit (ICU)-acquired paresis. This study was underpowered, so future larger studies are needed to confirm these findings. (LOE = 1b-)

Reference
Papazian L, Forel JM, Gacouin A, et al, for the ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Eng J Med 2010;363(12):1107-1116.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (ICU only)

Synopsis
These investigators randomized 340 adult patients presenting to the ICU with severe ARDS of 48 hours or less to receive either cisatracurium besylate or placebo. Severe ARDS was defined by the following: ratio of the partial pressure of arterial oxygen to the fraction of inspired oygen (PaO2:FIO2) of less than 150, positive end-expiratory pressure of 5 cm or more of water, and a tidal volume of 6 mL to 8 mL per kilogram of body weight. After achieving sedation, patients in each group received either cisatracurium or placebo at an initial 3 mL intravenous infusion of 15 mg, followed by a continuous infusion at 37.5 mg per hour for 48 hours. The 2 groups were balanced at baseline, except for a lower PaO2:FIO2 ratio in the cisatracurium group. The mean age of patients was 58 years and the majority of the patients were in the medical ICU. Follow-up was complete and analysis was by intention to treat. Although no significant difference was detected in crude 90-day mortality between the 2 groups (31.6% in cisatracurium group vs 40.7% in placebo group; P = .08), the study was underpowered to detect such a difference because of a lower-than-expected mortality rate in the placebo group. After adjusting for disease severity, baseline PaO2:FIO2 ratios, and plateau pressures, however, the risk of the primary outcome of 90-day mortality was reduced in the cisatracurium group (hazard ratio = 0.68; 95% CI, 0.48-0.98; P = .04). In addition, patients in the cisatracurium group had less barotrauma and pneumothoraces, more ventilator-free days, and more days outside the ICU. There was no difference in ICU-acquired paresis between the 2 groups on day 28 or at the time of ICU discharge.

Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL

Copyright © 2010 John Wiley & Sons, Inc.