Clinical Pearls & Morning Reports
Published May 22, 2019
The Prevention and Early Treatment of Acute Lung Injury (PETAL) Clinical Trials Network of the National Heart, Lung, and Blood Institute conducted the Reevaluation of Systemic Early Neuromuscular Blockade (ROSE) trial — a multicenter, unblinded, randomized trial of patients with moderate-to-severe acute respiratory distress syndrome (ARDS) — to determine the efficacy and safety of early neuromuscular blockade with concomitant heavy sedation as compared with a strategy of usual care with lighter sedation targets. Read the Original Article here.
Q: What are the advantages and disadvantages of neuromuscular blockade for patients with ARDS?
A: It is well established that the approaches used for the application of mechanical ventilation in patients with ARDS can affect survival and outcomes after discharge from the intensive care unit (ICU). For example, neuromuscular blockade reduces patient–ventilator dyssynchrony, the work of breathing, and the accumulation of alveolar fluid; patients with ARDS could benefit from these outcomes. However, prolonged administration of neuromuscular blocking agents is associated with subsequent neuromuscular weakness.
Q: Has early neuromuscular blockade been widely adopted for the management of ARDS?
A: Early neuromuscular blockade is not widely adopted and is only weakly recommended in current guidelines. Potential concerns include the lack of research comparing neuromuscular blockade and deep sedation with current practice (which promotes lighter sedation targets) as well as limited data on the effect of neuromuscular blockade on neuromuscular function and other long-term outcomes. In addition, neuromuscular blockade requires deep sedation, which itself can result in negative outcomes.
A: In a cohort of critically ill patients identified shortly after the diagnosis of moderate-to-severe ARDS, the addition of early continuous neuromuscular blockade with concomitant deep sedation did not result in lower mortality than a usual-care approach to mechanical ventilation that included lighter sedation targets. At 90 days, in-hospital death from any cause occurred in 213 patients (42.5%) in the intervention group and in 216 patients (42.8%) in the control group (between-group difference, –0.3 percentage points; 95% CI, –6.4 to 5.9; P=0.93). At 28 days, there was no between-group difference in hospital mortality, days free of ventilation, days out of the ICU, or days out of the hospital. The mean estimated mortality at 1 year was also not different between groups.
A: Recall of paralysis was uncommon and did not differ between groups. Patients in the control group had higher mean levels of physical activity up to day 6. The rates of ICU-acquired weakness assessed were not different between groups, but many patients (range, 51.2 to 67.5%) could not complete the weekly in-hospital assessments of muscle strength. More serious cardiovascular events were reported in the intervention group than in the control group (14 vs. 4 events; P=0.02), although the rates of new-onset atrial fibrillation and supraventricular tachycardia did not differ between groups.