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Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials.

Alhazzani W, Alshahrani M, Jaeschke R, Forel JM, Papazian L, Sevransky J, Meade MO - Crit Care (2013)

Bottom Line: Neuromuscular blockade was also associated with lower risk of barotrauma (RR, 0.43; 95% CI, 0.20 to 0.90; P=0.02; I2=0), but had no effect on the duration of mechanical ventilation among survivors (MD, 0.25 days; 95% CI, 5.48 to 5.99; P=0.93; I2=49%), or the risk of ICU-acquired weakness (RR, 1.08; 95% CI, 0.83 to 1.41; P=0.57; I2=0).Primary studies lacked protracted measurements of weakness.Short-term infusion of cisatracurium besylate reduces hospital mortality and barotrauma and does not appear to increase ICU-acquired weakness for critically ill adults with ARDS.

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ABSTRACT

Introduction: Randomized trials investigating neuromuscular blocking agents in adult acute respiratory distress syndrome (ARDS) have been inconclusive about effects on mortality, which is very high in this population. Uncertainty also exists about the associated risk of ICU-acquired weakness.

Methods: We conducted a systematic review and meta-analysis. We searched the Cochrane (Central) database, MEDLINE, EMBASE, ACP Journal Club, and clinical trial registries for randomized trials investigating survival effects of neuromuscular blocking agents in adults with ARDS. Two independent reviewers abstracted data and assessed methodologic quality. Primary study investigators provided additional unpublished data.

Results: Three trials (431 patients; 20 centers; all from the same research group in France) met inclusion criteria for this review. All trials assessed 48-hour infusions of cisatracurium besylate. Short-term infusion of cisatracurium besylate was associated with lower hospital mortality (RR, 0.72; 95% CI, 0.58 to 0.91; P=0.005; I2=0). This finding was robust on sensitivity analyses. Neuromuscular blockade was also associated with lower risk of barotrauma (RR, 0.43; 95% CI, 0.20 to 0.90; P=0.02; I2=0), but had no effect on the duration of mechanical ventilation among survivors (MD, 0.25 days; 95% CI, 5.48 to 5.99; P=0.93; I2=49%), or the risk of ICU-acquired weakness (RR, 1.08; 95% CI, 0.83 to 1.41; P=0.57; I2=0). Primary studies lacked protracted measurements of weakness.

Conclusions: Short-term infusion of cisatracurium besylate reduces hospital mortality and barotrauma and does not appear to increase ICU-acquired weakness for critically ill adults with ARDS.

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Summary of evidence search and selection. Flow diagram showing steps of study selection.
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Figure 1: Summary of evidence search and selection. Flow diagram showing steps of study selection.

Mentions: After screening 740 titles and abstracts, we found three trials eligible for this review (Figure 1). All three trials originated from the same group of investigators, including a total of 431 patients, and one trial was conducted in 20 centers in France. The trials were specifically designed to investigate the effects of cisatracurium besylate, a benzylisoquinoline compound, on gas exchange [12], inflammatory markers [13], and clinically important outcomes [14], respectively. In each trial, cisatracurium besylate was infused for 48 hours, by using weight-based dosing in two trials [12,13], and a fixed high dose (15 mg bolus, followed by a continuous infusion of 37.5 mg per hour) in the other (Table 1) [14]. All three trials reported 28-day mortality, barotraumas, and ICU-acquired weakness; and these data were supplemented by additional, previously unpublished data from the study investigators.


Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials.

Alhazzani W, Alshahrani M, Jaeschke R, Forel JM, Papazian L, Sevransky J, Meade MO - Crit Care (2013)

Summary of evidence search and selection. Flow diagram showing steps of study selection.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3672502&req=5

Figure 1: Summary of evidence search and selection. Flow diagram showing steps of study selection.
Mentions: After screening 740 titles and abstracts, we found three trials eligible for this review (Figure 1). All three trials originated from the same group of investigators, including a total of 431 patients, and one trial was conducted in 20 centers in France. The trials were specifically designed to investigate the effects of cisatracurium besylate, a benzylisoquinoline compound, on gas exchange [12], inflammatory markers [13], and clinically important outcomes [14], respectively. In each trial, cisatracurium besylate was infused for 48 hours, by using weight-based dosing in two trials [12,13], and a fixed high dose (15 mg bolus, followed by a continuous infusion of 37.5 mg per hour) in the other (Table 1) [14]. All three trials reported 28-day mortality, barotraumas, and ICU-acquired weakness; and these data were supplemented by additional, previously unpublished data from the study investigators.

Bottom Line: Neuromuscular blockade was also associated with lower risk of barotrauma (RR, 0.43; 95% CI, 0.20 to 0.90; P=0.02; I2=0), but had no effect on the duration of mechanical ventilation among survivors (MD, 0.25 days; 95% CI, 5.48 to 5.99; P=0.93; I2=49%), or the risk of ICU-acquired weakness (RR, 1.08; 95% CI, 0.83 to 1.41; P=0.57; I2=0).Primary studies lacked protracted measurements of weakness.Short-term infusion of cisatracurium besylate reduces hospital mortality and barotrauma and does not appear to increase ICU-acquired weakness for critically ill adults with ARDS.

View Article: PubMed Central - HTML - PubMed

ABSTRACT

Introduction: Randomized trials investigating neuromuscular blocking agents in adult acute respiratory distress syndrome (ARDS) have been inconclusive about effects on mortality, which is very high in this population. Uncertainty also exists about the associated risk of ICU-acquired weakness.

Methods: We conducted a systematic review and meta-analysis. We searched the Cochrane (Central) database, MEDLINE, EMBASE, ACP Journal Club, and clinical trial registries for randomized trials investigating survival effects of neuromuscular blocking agents in adults with ARDS. Two independent reviewers abstracted data and assessed methodologic quality. Primary study investigators provided additional unpublished data.

Results: Three trials (431 patients; 20 centers; all from the same research group in France) met inclusion criteria for this review. All trials assessed 48-hour infusions of cisatracurium besylate. Short-term infusion of cisatracurium besylate was associated with lower hospital mortality (RR, 0.72; 95% CI, 0.58 to 0.91; P=0.005; I2=0). This finding was robust on sensitivity analyses. Neuromuscular blockade was also associated with lower risk of barotrauma (RR, 0.43; 95% CI, 0.20 to 0.90; P=0.02; I2=0), but had no effect on the duration of mechanical ventilation among survivors (MD, 0.25 days; 95% CI, 5.48 to 5.99; P=0.93; I2=49%), or the risk of ICU-acquired weakness (RR, 1.08; 95% CI, 0.83 to 1.41; P=0.57; I2=0). Primary studies lacked protracted measurements of weakness.

Conclusions: Short-term infusion of cisatracurium besylate reduces hospital mortality and barotrauma and does not appear to increase ICU-acquired weakness for critically ill adults with ARDS.

Show MeSH
Related in: MedlinePlus