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Randomized Controlled Trial
. 2021 Apr 1;132(4):1051-1059.
doi: 10.1213/ANE.0000000000005174.

Neuromuscular Blockade Monitoring in Acute Respiratory Distress Syndrome: Randomized Controlled Trial of Clinical Assessment Alone or With Peripheral Nerve Stimulation

Saïda Rezaiguia-Delclaux  1 , Florent Laverdure  1 , Thibaut Genty  1 , Audrey Imbert  1 , Catherine Pilorge  1 , Priscilla Amaru  1 , Céline Sarfati  2 , François Stéphan  1
Affiliations
Randomized Controlled Trial

Neuromuscular Blockade Monitoring in Acute Respiratory Distress Syndrome: Randomized Controlled Trial of Clinical Assessment Alone or With Peripheral Nerve Stimulation

Saïda Rezaiguia-Delclaux et al. Anesth Analg. .

Abstract

Background: Whether train-of-four (TOF) monitoring is more effective than clinical monitoring to guide neuromuscular blockade (NMB) in patients with acute respiratory distress syndrome (ARDS) is unclear. We compared clinical monitoring alone or with TOF monitoring to guide atracurium dosage adjustment with respect to drug dose and respiratory parameters.

Methods: From 2015 to 2016, we conducted a randomized controlled trial comparing clinical assessments every 2 hours with or without corrugator supercilii TOF monitoring every 4 hours in patients who developed ARDS (Pao2/Fio2 <150 mm Hg) in a cardiothoracic intensive care unit. The primary outcome was the cumulative atracurium dose (mg/kg/h). Secondary outcomes included respiratory parameters during the neuromuscular blockade.

Results: A total of 38 patients in the clinical + TOF (C + TOF) group and 39 patients in the clinical (C) group were included in an intention-to-treat (ITT) analysis. The cumulative atracurium dose was higher in the C + TOF group (1.06 [0.75-1.30] vs 0.65 [0.60-0.89] mg/kg/h in the C group; P < .001) compared to C group, as well as the atracurium daily dose (C + TOF - C group mean difference = 0.256 mg/kg/h [95% confidence interval {CI}, 0.099-0.416], P = .026). Driving pressures during neuromuscular blocking agent (NMBA) administration did not differ between groups (P = .653). Intensive care unit (ICU) mortality was 22% in the C group and 27% in the C + TOF group (P = .786). Days on ventilation were 17 (8-26) in the C group and 16 (10-35) in the C + TOF group.

Conclusions: In patients with ARDS, adding TOF to clinical monitoring of neuromuscular blockade did not change ICU mortality or days on mechanical ventilation (MV) but did increase atracurium consumption when compared to clinical assessment alone. TOF monitoring may not be needed in all patients who receive neuromuscular blockade for ARDS.

Trial registration: ClinicalTrials.gov NCT02546947.

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Conflict of interest statement

Conflicts of Interest: See Disclosures at the end of the article.

Comment in

  • Neuromuscular Blocking Agents in the ICU: Why Work Blindfolded?
    Rosboch GL, Ceraolo E, Balzani E, Brazzi L. Rosboch GL, et al. Anesth Analg. 2021 May 1;132(5):e73. doi: 10.1213/ANE.0000000000005353. Anesth Analg. 2021. PMID: 33857989 No abstract available.
  • In Response.
    Rezaiguia-Delclaux S, Stéphan F. Rezaiguia-Delclaux S, et al. Anesth Analg. 2021 May 1;132(5):e74. doi: 10.1213/ANE.0000000000005354. Anesth Analg. 2021. PMID: 33857990 No abstract available.

References

    1. Murray MJ, DeBlock H, Erstad B, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2016;44:2079–2103.
    1. Papazian L, Aubron C, Laurent Brochard L, et al. SDRA: Les recommandations de la SRLF. SRLF. January 2019. Available at: https://www.srlf.org/rfe-srlf-prise-en-charge-du-syndrome-de-detresse-re... . Accessed May 12, 2019.
    1. Papazian L, Forel JM, Gacouin A, et al.; ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107–1116.
    1. Moss M, Huang DT, Brower RG, et al.; National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med. 2019;380:1997–2008.
    1. Hermans G, Casaer MP, Clerckx B, et al. Effect of tolerating macronutrient deficit on the development of intensive-care unit acquired weakness: a subanalysis of the EPaNIC trial. Lancet Respir Med. 2013;1:621–629.

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