In this episode, I’ll discuss the optimal sedation strategy in patients with ARDS who receive NMBAs.
The two large trials regarding neuromuscular blocking agents (NMBAs) in patients with acute respiratory distress syndrome (ARDS) (ACURASYS and ROSE) produced ambiguous results regarding the utility of NMBAs in these patients. One possibility for this was the discordance in sedation regimens between the two trials.
Researchers at Beth Israel Deaconess Medical Center in Boston, MA recently published a retrospective cohort study looking at whether the proportion of deeper sedation in ARDS patients is a mediator of the effect of neuromuscular blocking agent infusions on mortality.
Over 3400 patients were included and nearly 600 of them received NMBAs.
The authors used mediation analysis to attempt to isolate the effects of neuromuscular blockers and deep sedation on mortality in ARDS patients.
Despite the mean duration of NMBA infusion being 1.8 days, the authors found that the mean duration of deeper sedation was prolonged by 2.2 additional days in the NMBA group compared to the group that did not receive NMBAs.
This finding suggested that after NMBAs are stopped, deeper sedation is unnecessarily prolonged.
When the authors did not include the proportion of patients who received deeper sedation as a confounder, NMBA infusions were associated with increased mortality by nearly 11 absolute percentage points.
However, when this confounder was accounted for, the authors found that in ARDS patients that require deep sedation to achieve oxygenation, adding neuromuscular blockers removes the negative mortality effect of deep sedation.
The authors concluded:
In ARDS patients who receive NMBA infusions, a prolonged, high proportion of deeper sedation is associated with increased mortality. Based on our findings,
we suggest that clinicians should minimize the duration of deeper sedation after recovery from NMBA
infusions. Our data support the use of NMBA infusions in patients who need deeper sedation to achieve
The authors acknowledge that a retrospective design such as this study is a limitation as there may be additional confounders that were not accounted for. Until confirmation with a prospective trial, this data does support the idea that NMBA infusions should not be used when lung-protective ventilation can be achieved with light sedation, and suggests that adding them when deep sedation is necessary is beneficial. In addition, pharmacists can keep an eye out for the end time of NMBA infusions and provide education to facilitate a faster end to deeper sedation.
Members of my Hospital Pharmacy Academy have access to practical trainings on neuromuscular blocking agents, and specific issues like steroids and NMBA use in ARDS patients. This is in addition to over 150 other practical trainings. To get immediate access to these and many other resources to help in your practice, go to pharmacyjoe.com/academy.
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