- Among patients with acute respiratory distress syndrome (ARDS) undergoing mechanical ventilation (MV) with high positive end-expiratory pressure (PEEP), neuromuscular blockade (NMB) did not lower mortality vs usual care with lighter sedation.
- Editorial :
- Suggests difference in sedation vs ACURASYS could explain discordant results.
- Recommends against routine NMB in moderate-to-severe ARDS, unless breath stacking or increased respiratory drive.
- Postulates dyssynchrony may affect outcomes.
Why this matters
- In ACURASYS (2010), NMB reduced ARDS mortality vs deep sedation alone, yet intervention seldom used:
- Modern practice favors lighter sedation.
- Little is known about NMB's downstream outcomes.
- Randomized multicenter controlled open-label ROSE trial (n=1006).
- Researchers randomly assigned participants with moderate-to-severe ARDS undergoing MV to either:
- 48-hour continuous cisatracurium (Nimbex; AbbVie, Inc.) plus deep sedation, or
- Usual care without routine NMB; with lighter sedation (controls).
- Both groups underwent high-PEEP mechanical ventilation, conservative fluid strategy.
- Outcome: 90-day in-hospital mortality.
- Funding: NIH.
- High protocol adherence.
- Trial halted for futility.
- Cisatracurium vs control:
- Primary outcome: 42.5% vs 42.8%; between-group difference, −0.3% (95% CI, −6.4 to 5.9; P=.93).
- Serious cardiovascular events: 14 vs 4 (P=.02).
- No differences in 28-day hospital mortality; ventilation-, ICU-, or hospital-free days; pneumothorax; barotrauma.
- 1 death possibly related to cisatracurium.