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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.

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 Primary study investigators provided additional unpublished data.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.

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Mortality. Forest plot comparing neuromuscular blockers and placebo for the following outcomes: 28 days, ICU, and hospital (truncated at 90 days), results are shown by using random-effects model with relative risk and 95% confidence interval.
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Figure 2: Mortality. Forest plot comparing neuromuscular blockers and placebo for the following outcomes: 28 days, ICU, and hospital (truncated at 90 days), results are shown by using random-effects model with relative risk and 95% confidence interval.

Mentions: Cisatracurium besylate was associated with lower risk of death at 28 days (RR, 0.66; 95% CI, 0.50 to 0.87; P = 0.003; I2 = 0; Figure 2), at ICU discharge (RR, 0.70; 95% CI, 0.55 to 0.89; P = 0.004; I2 , 0; Figure 2), and at hospital discharge (RR, 0.72; 95% CI, 0.58 to 0.91; P = 0.005; I2 = 0; Figure 2). Assuming a mortality rate of 40% in the absence of cisatracurium therapy at each of these time points, these pooled estimates suggest a number needed to treat of seven patients (95% CI, 5 to 19) to save one additional life at 28 days; eight patients (95% CI, 4 to 31) to save one additional life at ICU discharge; and nine patients (95% CI, 6 to 27) for hospital mortality (Table 3).


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)

Mortality. Forest plot comparing neuromuscular blockers and placebo for the following outcomes: 28 days, ICU, and hospital (truncated at 90 days), results are shown by using random-effects model with relative risk and 95% confidence interval.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 2: Mortality. Forest plot comparing neuromuscular blockers and placebo for the following outcomes: 28 days, ICU, and hospital (truncated at 90 days), results are shown by using random-effects model with relative risk and 95% confidence interval.
Mentions: Cisatracurium besylate was associated with lower risk of death at 28 days (RR, 0.66; 95% CI, 0.50 to 0.87; P = 0.003; I2 = 0; Figure 2), at ICU discharge (RR, 0.70; 95% CI, 0.55 to 0.89; P = 0.004; I2 , 0; Figure 2), and at hospital discharge (RR, 0.72; 95% CI, 0.58 to 0.91; P = 0.005; I2 = 0; Figure 2). Assuming a mortality rate of 40% in the absence of cisatracurium therapy at each of these time points, these pooled estimates suggest a number needed to treat of seven patients (95% CI, 5 to 19) to save one additional life at 28 days; eight patients (95% CI, 4 to 31) to save one additional life at ICU discharge; and nine patients (95% CI, 6 to 27) for hospital mortality (Table 3).

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