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. 2021 Jul 1;49(7):1137-1148.
doi: 10.1097/CCM.0000000000004951.

Optimal Sedation in Patients Who Receive Neuromuscular Blocking Agent Infusions for Treatment of Acute Respiratory Distress Syndrome-A Retrospective Cohort Study From a New England Health Care Network

Karuna Wongtangman  1   2 , Stephanie D Grabitz  1 , Maximilian Hammer  1 , Luca J Wachtendorf  1 , Xinling Xu  1 , Maximilian S Schaefer  1 , Philipp Fassbender  1   3 , Peter Santer  1 , Elias Baedorf Kassis  3 , Daniel Talmor  1 , Matthias Eikermann  1 ; SICU Optimal Mobilization Team (SOMT) Group
Affiliations

Optimal Sedation in Patients Who Receive Neuromuscular Blocking Agent Infusions for Treatment of Acute Respiratory Distress Syndrome-A Retrospective Cohort Study From a New England Health Care Network

Karuna Wongtangman et al. Crit Care Med. .

Abstract

Objectives: Two previously published trials (ARDS et Curarisation Systematique [ACURASYS] and Reevaluation of Systemic Early Neuromuscular Blockade [ROSE]) presented equivocal evidence on the effect of neuromuscular blocking agent infusions in patients with acute respiratory distress syndrome (acute respiratory distress syndrome). The sedation regimen differed between these trials and also within the ROSE trial between treatment and control groups. We hypothesized that the proportion of deeper sedation is a mediator of the effect of neuromuscular blocking agent infusions on mortality.

Design: Retrospective cohort study.

Setting: Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA).

Patients: Intubated and mechanically ventilated ICU patients with acute respiratory distress syndrome (Berlin definition) admitted between January 2008 until June 2019.

Interventions: None.

Measurements and main results: The proportion of deeper sedation was defined as days with nonlight sedation as a fraction of mechanical ventilation days in the ICU after acute respiratory distress syndrome diagnosis. Using clinical data obtained from a hospital network registry, 3,419 patients with acute respiratory distress syndrome were included, of whom 577 (16.9%) were treated with neuromuscular blocking agent infusions, for a mean (sd) duration of 1.8 (±1.9) days. The duration of deeper sedation was prolonged in patients receiving neuromuscular blocking agent infusions (4.6 ± 2.2 d) compared with patients without neuromuscular blocking agent infusions (2.4 ± 2.2 d; p < 0.001). The proportion of deeper sedation completely mediated the negative effect of neuromuscular blocking agent infusions on in-hospital mortality (p < 0.001). Exploratory analysis in patients who received deeper sedation revealed a beneficial effect of neuromuscular blocking agent infusions on mortality (49% vs 51%; adjusted odds ratio, 0.80; 95% CI, 0.63-0.99, adjusted absolute risk difference, -0.05; p = 0.048).

Conclusions: In acute respiratory distress syndrome patients who receive neuromuscular blocking agent infusions, a prolonged, high proportion of deeper sedation is associated with increased mortality. Our data support the view that clinicians should minimize the duration of deeper sedation after recovery from neuromuscular blocking agent infusion.

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Conflict of interest statement

Dr. Kassis received Educational Lecturing Fees for Hamilton Medical Inc. Dr. Talmor received funds from the National Heart, Lung, and Blood Institute for the Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network. Dr. Eikermann received funding from Merck and received philanthropic donations from Jeffrey and Judy Buzen. Funds from Jeffrey and Judy Buzen were allotted to support time and effort of study personnel. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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