Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome

被引：536

作者：

Moss, Marc ^{[1
]}

Huang, David T. ^{[3
]}

Brower, Roy G. ^{[5
]}

Ferguson, Niall D. ^{[6
,7
]}

Ginde, Adit A. ^{[2
]}

Gong, M. N. ^{[8
]}

Grissom, Colin K. ^{[9
,10
]}

Gundel, Stephanie ^{[11
]}

Hayden, Douglas ^{[12
]}

Hite, R. Duncan ^{[17
]}

Hou, Peter C. ^{[15
]}

Hough, Catherine L. ^{[11
]}

Iwashyna, Theodore J. ^{[18
,19
]}

Khan, Akram ^{[20
]}

Liu, Kathleen D. ^{[21
,22
]}

Talmor, Daniel ^{[16
]}

Thompson, B. Taylor ^{[13
]}

Ulysse, Christine A. ^{[14
]}

Yealy, Donald M. ^{[4
]}

Angus, Derek C. ^{[3
]}

机构：

[1] Univ Colorado, Sch Med, Dept Med, Aurora, CO USA

[2] Univ Colorado, Sch Med, Dept Emergency Med, Aurora, CO USA

[3] Univ Pittsburgh, Sch Med, Dept Crit Care Med, Pittsburgh, PA USA

[4] Univ Pittsburgh, Sch Med, Dept Emergency Med, Pittsburgh, PA USA

[5] Johns Hopkins Univ, Sch Med, Dept Med, Baltimore, MD 21205 USA

[6] Univ Hlth Network, Dept Med, Interdept Div Crit Care Med, Toronto, ON, Canada

[7] Univ Toronto, Sinai Hlth Syst, Toronto, ON, Canada

[8] Montefiore Hosp, Dept Med, New York, NY USA

[9] Intermt Med Ctr, Dept Med, Salt Lake City, UT USA

[10] Univ Utah, Salt Lake City, UT USA

[11] Univ Washington, Dept Med, Seattle, WA USA

[12] Massachusetts Gen Hosp, Biostat Ctr, Boston, MA 02114 USA

[13] Massachusetts Gen Hosp, Dept Med, Boston, MA 02114 USA

[14] Massachusetts Gen Hosp, PETAL Network Clin Coordinating Ctr, Boston, MA 02114 USA

[15] Brigham & Womens Hosp, Dept Emergency Med, Div Emergency Crit Care Med, 75 Francis St, Boston, MA 02115 USA

[16] Beth Israel Deaconess Med Ctr, Dept Anesthesia Crit Care & Pain Med, Boston, MA 02215 USA

[17] Cleveland Clin, Resp Inst, Dept Crit Care, Cleveland, OH 44106 USA

[18] Univ Michigan, Dept Med, Ann Arbor, MI 48109 USA

[19] Vet Affairs Ctr Clin Res, Ann Arbor, MI USA

[20] Oregon Hlth & Sci Univ, Dept Med, Portland, OR 97201 USA

[21] Univ Calif San Francisco, Dept Med, San Francisco, CA USA

[22] Univ Calif San Francisco, Dept Anesthesia, San Francisco, CA USA

来源：

NEW ENGLAND JOURNAL OF MEDICINE | 2019年 / 380卷 / 21期

关键词：

MECHANICALLY VENTILATED PATIENTS; INTENSIVE-CARE UNIT; NONLINEAR IMPUTATION; BLOCKING-AGENTS; SEDATION; RELIABILITY; MORTALITY; ICU; AGITATION; WEAKNESS;

D O I：

10.1056/NEJMoa1901686

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

Background The benefits of early continuous neuromuscular blockade in patients with acute respiratory distress syndrome (ARDS) who are receiving mechanical ventilation remain unclear. Methods We randomly assigned patients with moderate-to-severe ARDS (defined by a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure [PEEP] of >= 8 cm of water) to a 48-hour continuous infusion of cisatracurium with concomitant deep sedation (intervention group) or to a usual-care approach without routine neuromuscular blockade and with lighter sedation targets (control group). The same mechanical-ventilation strategies were used in both groups, including a strategy involving a high PEEP. The primary end point was in-hospital death from any cause at 90 days. Results The trial was stopped at the second interim analysis for futility. We enrolled 1006 patients early after the onset of moderate-to-severe ARDS (median, 7.6 hours after onset). During the first 48 hours after randomization, 488 of the 501 patients (97.4%) in the intervention group started a continuous infusion of cisatracurium (median duration of infusion, 47.8 hours; median dose, 1807 mg), and 86 of the 505 patients (17.0%) in the control group received a neuromuscular blocking agent (median dose, 38 mg). At 90 days, 213 patients (42.5%) in the intervention group and 216 (42.8%) in the control group had died before hospital discharge (between-group difference, -0.3 percentage points; 95% confidence interval, -6.4 to 5.9; P=0.93). While in the hospital, patients in the intervention group were less physically active and had more adverse cardiovascular events than patients in the control group. There were no consistent between-group differences in end points assessed at 3, 6, and 12 months. Conclusions Among patients with moderate-to-severe ARDS who were treated with a strategy involving a high PEEP, there was no significant difference in mortality at 90 days between patients who received an early and continuous cisatracurium infusion and those who were treated with a usual-care approach with lighter sedation targets. (Funded by the National Heart, Lung, and Blood Institute; ROSE ClinicalTrials.gov number, .) This trial revisited research conducted about a decade ago that showed a survival benefit with early neuromuscular blockade in patients with acute respiratory distress syndrome. The new trial did not show a benefit with neuromuscular blockade with respect to overall survival or other clinical outcomes.

引用

页码：1997 / 2008

页数：12

共 43 条

[21] DRUG-THERAPY - NEW NEUROMUSCULAR BLOCKING-DRUGS [J].