"Cisatracurium in Early Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2010. 363(12):1107-1116. PubMed
Links to original sources: Wiki Journal Post Full Journal Article
Contents 1 Clinical Question 2 Bottom Line 3 Major Points 4 Guidelines 5 Design 6 Population 6.1 Inclusion Criteria 6.2 Exclusion Criteria 6.3 Baseline Characteristics 7 Interventions 8 Outcomes 8.1 Primary Outcomes 8.2 Secondary Outcomes 9 Criticisms 10 Funding 11 Further Reading
In patients with early, severe ARDS, does administration of neuromuscular blocking agent (cisatracurium) for 48 hours improve clinical outcomes?
In patients with early, severe ARDS, administration of cisatracurium for 48 hours improved the adjusted 90-day survival rate, increased time off the ventilator without increasing muscle weakness, but did not significantly improve the overall 90-day mortality.
The use of neuromuscular blocking agents in patients with ARDS is recommended for facilitating mechanical ventilation when sedation alone is inadequate. The ACURASYS trial aimed to evaluate the effects of a 48-hour cisatracurium infusion in patients with severe ARDS. The trial found that cisatracurium improved adjusted 90-day survival, increased ventilator-free days, and provided more ICU-free days without an increase in muscle weakness.
Current guidelines suggest that neuromuscular blocking agents are appropriate for facilitating mechanical ventilation in patients with severe ARDS when sedation is inadequate, but the study's findings need further replication and expansion before wider clinical adoption.
Multicenter, double-blind, parallel-group, randomized, placebo-controlled trial.
A total of 340 patients with severe ARDS.
Inclusion Criteria - Endotracheal mechanical ventilation for acute hypoxemic respiratory failure - PaO2:FIO2 less than 150 with ventilator set to deliver a positive end-expiratory pressure of 5 cm H2O or higher and a tidal volume of 6 to 8 ml/kg of predicted body weight.
Exclusion Criteria - Left atrial hypertension - Neuromuscular disease - Pregnant or breastfeeding - Extreme obesity
Baseline Characteristics There were no significant differences between the groups except for a lower mean PaO2:FIO2 in the cisatracurium group.
Patients were randomized to receive either cisatracurium besylate or placebo for 48 hours.
Primary Outcomes - 90-day in-hospital mortality rate - Adjusted hazard ratio for death at 90 days was 0.68 in the cisatracurium group versus placebo.
- 28-day mortality - Ventilator-free days - Days without organ failure - Rate of barotrauma - Rate of ICU-acquired paresis - MRC scores on day 28 and at ICU discharge
- Results are specific to cisatracurium and might not apply to other neuromuscular blocking agents - The absence of data on conditions that might affect neuromuscular blockade effectiveness - Underpowered because the observed mortality rate was lower than expected in the placebo group
Assistance Publique–Hôpitaux de Marseille and a grant from the Ministère de la Santé.
The full list of articles for further reading is available with the full text of this article at NEJM.org.