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Meta-Analysis
. 2005 Apr 18;2005(2):CD002773.
doi: 10.1002/14651858.CD002773.pub2.

Neuromuscular paralysis for newborn infants receiving mechanical ventilation

F Cools  1 , M Offringa
Affiliations
Meta-Analysis

Neuromuscular paralysis for newborn infants receiving mechanical ventilation

F Cools et al. Cochrane Database Syst Rev. .

Abstract

Background: Ventilated newborn infants breathing in asynchrony with the ventilator are at risk for complications during mechanical ventilation, such as pneumothorax or intraventricular hemorrhage, and are exposed to more severe barotrauma, which consequently could impair their clinical outcome. Neuromuscular paralysis, which eliminates spontaneous breathing efforts of the infant, has potential advantages in this respect. However, a number of complications have been reported with muscle relaxation in infants, so that concerns exist regarding the safety of prolonged neuromuscular paralysis in newborn infants.

Objectives: To determine whether routine neuromuscular paralysis of newborn infants receiving mechanical ventilation compared with no routine paralysis results in clinically important benefits or harms.

Search strategy: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2004), MEDLINE (from 1966 to April 2004) and EMBASE (from 1988 to April 2004) were searched. References of review articles were hand searched. Language restriction was not imposed.

Selection criteria: All trials using random or quasi-random patient allocation, in which the routine use of neuromuscular blocking agents during mechanical ventilation was compared to no paralysis or selective paralysis in newborn infants. Methodological quality was assessed blindly and independently by the two authors.

Data collection and analysis: Data were abstracted using standard methods of the Cochrane Collaboration and its Neonatal Review Group, with independent evaluation of trial quality, and abstraction and synthesis of data by both authors. Treatment effect was analysed using relative risk, risk difference and weighted mean difference.

Main results: Ten possibly eligible trials were identified, of which six were included in the review. All the included trials studied preterm infants ventilated for respiratory distress syndrome, and used pancuronium as the neuromuscular blocking agent. In the analysis of the results of all trials, no significant difference was found in mortality, air leak or chronic lung disease, but there was a significant reduction in intraventricular hemorrhage and a trend towards less severe intraventricular hemorrhages. In the subgroup analysis of trials studying a selected population of ventilated infants with evidence of asynchronous respiratory efforts, a significant reduction in intraventricular hemorrhage (any grade and severe IVH) was found, and a trend towards less air leak. In the subgroup analysis of trials studying an unselected population of ventilated infants, no significant differences were found for any of the outcomes.

Authors' conclusions: For ventilated preterm infants with evidence of asynchronous respiratory efforts, neuromuscular paralysis with pancuronium seems to have a favourable effect on intraventricular hemorrhage and possibly on air leak. Uncertainty remains, however, regarding the long term pulmonary and neurologic effects, and regarding the safety of prolonged use of pancuronium in ventilated newborn infants. There is no evidence from randomized trials on the effects of neuromuscular blocking agents other than pancuronium. The routine use of pancuronium or any other neuromuscular blocking agent in ventilated newborn infants cannot be recommended based on current evidence.

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Conflict of interest statement

None

Figures

1.1
1.1. Analysis
Comparison 1 Routine paralysis versus no/selective paralysis (all trials), Outcome 1 Mortality before discharge.
1.2
1.2. Analysis
Comparison 1 Routine paralysis versus no/selective paralysis (all trials), Outcome 2 Mortality at 28 days.
1.3
1.3. Analysis
Comparison 1 Routine paralysis versus no/selective paralysis (all trials), Outcome 3 Pneumothorax (with or without pulmonary interstitial emphysema).
1.4
1.4. Analysis
Comparison 1 Routine paralysis versus no/selective paralysis (all trials), Outcome 4 Any air leak (pneumothorax or interstitial pulmonary emphysema).
1.5
1.5. Analysis
Comparison 1 Routine paralysis versus no/selective paralysis (all trials), Outcome 5 IVH (any grade).
1.6
1.6. Analysis
Comparison 1 Routine paralysis versus no/selective paralysis (all trials), Outcome 6 Severe IVH (grade 3 or 4).
1.7
1.7. Analysis
Comparison 1 Routine paralysis versus no/selective paralysis (all trials), Outcome 7 CLD at 28 days postnatal age in survivors.
1.8
1.8. Analysis
Comparison 1 Routine paralysis versus no/selective paralysis (all trials), Outcome 8 CLD at 36 weeks postmenstrual age in survivors.
1.9
1.9. Analysis
Comparison 1 Routine paralysis versus no/selective paralysis (all trials), Outcome 9 Cystic PVL.
2.1
2.1. Analysis
Comparison 2 Routine paralysis versus no/selective paralysis (trials selecting for asynchrony at entry), Outcome 1 Mortality before discharge.
2.2
2.2. Analysis
Comparison 2 Routine paralysis versus no/selective paralysis (trials selecting for asynchrony at entry), Outcome 2 Pneumothorax (with or without pulmonary interstitial emphysema).
2.3
2.3. Analysis
Comparison 2 Routine paralysis versus no/selective paralysis (trials selecting for asynchrony at entry), Outcome 3 Any air leak (pneumothorax or interstitial pulmonary emphysema).
2.4
2.4. Analysis
Comparison 2 Routine paralysis versus no/selective paralysis (trials selecting for asynchrony at entry), Outcome 4 IVH (any grade).
2.5
2.5. Analysis
Comparison 2 Routine paralysis versus no/selective paralysis (trials selecting for asynchrony at entry), Outcome 5 Severe IVH (grade 3 or 4).
3.1
3.1. Analysis
Comparison 3 Routine paralysis versus no/selective paralysis (trials not selecting for asynchrony at entry), Outcome 1 Mortality before discharge.
3.2
3.2. Analysis
Comparison 3 Routine paralysis versus no/selective paralysis (trials not selecting for asynchrony at entry), Outcome 2 Mortality at 28 days.
3.3
3.3. Analysis
Comparison 3 Routine paralysis versus no/selective paralysis (trials not selecting for asynchrony at entry), Outcome 3 Pneumothorax (with or without pulmonary interstitial emphysema).
3.4
3.4. Analysis
Comparison 3 Routine paralysis versus no/selective paralysis (trials not selecting for asynchrony at entry), Outcome 4 Severe IVH (grade 3 or 4).
3.5
3.5. Analysis
Comparison 3 Routine paralysis versus no/selective paralysis (trials not selecting for asynchrony at entry), Outcome 5 CLD at 28 days postnatal age in survivors.
3.6
3.6. Analysis
Comparison 3 Routine paralysis versus no/selective paralysis (trials not selecting for asynchrony at entry), Outcome 6 CLD at 36 weeks postmenstrual age in survivors.
3.7
3.7. Analysis
Comparison 3 Routine paralysis versus no/selective paralysis (trials not selecting for asynchrony at entry), Outcome 7 Cystic PVL.
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References

References to studies included in this review

Bancalari 1980 {published data only}
    1. Bancalari E, Gerhardt T, Feller R, Gannon J, Melnick G, Abdenour G. Muscle relaxation during IPPV in premature infants with RDS. Pediatric Research 1980;14:590.
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Greenough 1984 {published data only}
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Finer 1981 {published data only}
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References to other published versions of this review

Cools 2000
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