Giuseppe
Emeritus
Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome (N Engl J Med., abstract, edited)
[Source: The New England Journal of Medicine, free abstract: <cite cite="http://www.nejm.org/doi/full/10.1056/NEJMoa1005372?query=TOC">Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome ? NEJM</cite>. Edited.]
Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome
Laurent Papazian, M.D., Ph.D., Jean-Marie Forel, M.D., Arnaud Gacouin, M.D., Christine Penot-Ragon, Pharm.D., Gilles Perrin, M.D., Anderson Loundou, Ph.D., Samir Jaber, M.D., Ph.D., Jean-Michel Arnal, M.D., Didier Perez, M.D., Jean-Marie Seghboyan, M.D., Jean-Michel Constantin, M.D., Ph.D., Pierre Courant, M.D., Jean-Yves Lefrant, M.D., Ph.D., Claude Gu?rin, M.D., Ph.D., Gwena?l Prat, M.D., Sophie Morange, M.D., and Antoine Roch, M.D., Ph.D. for the ACURASYS Study Investigators
N Engl J Med 2010; 363:1107-1116
September 16, 2010
Background
In patients undergoing mechanical ventilation for the acute respiratory distress syndrome (ARDS), neuromuscular blocking agents may improve oxygenation and decrease ventilator-induced lung injury but may also cause muscle weakness. We evaluated clinical outcomes after 2 days of therapy with neuromuscular blocking agents in patients with early, severe ARDS.
Methods
In this multicenter, double-blind trial, 340 patients presenting to the intensive care unit (ICU) with an onset of severe ARDS within the previous 48 hours were randomly assigned to receive, for 48 hours, either cisatracurium besylate (178 patients) or placebo (162 patients). Severe ARDS was defined as a ratio of the partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen (FIO2) of less than 150, with a positive end-expiratory pressure of 5 cm or more of water and a tidal volume of 6 to 8 ml per kilogram of predicted body weight. The primary outcome was the proportion of patients who died either before hospital discharge or within 90 days after study enrollment (i.e., the 90-day in-hospital mortality rate), adjusted for predefined covariates and baseline differences between groups with the use of a Cox model.
Results
The hazard ratio for death at 90 days in the cisatracurium group, as compared with the placebo group, was 0.68 (95% confidence interval [CI], 0.48 to 0.98; P=0.04), after adjustment for both the baseline PaO2:FIO2 and plateau pressure and the Simplified Acute Physiology II score. The crude 90-day mortality was 31.6% (95% CI, 25.2 to 38.8) in the cisatracurium group and 40.7% (95% CI, 33.5 to 48.4) in the placebo group (P=0.08). Mortality at 28 days was 23.7% (95% CI, 18.1 to 30.5) with cisatracurium and 33.3% (95% CI, 26.5 to 40.9) with placebo (P=0.05). The rate of ICU-acquired paresis did not differ significantly between the two groups.
Conclusions
In patients with severe ARDS, early administration of a neuromuscular blocking agent improved the adjusted 90-day survival and increased the time off the ventilator without increasing muscle weakness.
(Funded by Assistance Publique?H?pitaux de Marseille and the Programme Hospitalier de Recherche Clinique R?gional 2004-26 of the French Ministry of Health; ClinicalTrials.gov number, NCT00299650.)
Source Information
From Assistance Publique?H?pitaux de Marseille Unit? de Recherche sur les Maladies Infectieuses et Tropicales ?mergentes (URMITE), Centre National de la Recherche Scientifique?Unit? Mixte de Recherche (CNRS-UMR) 6236 (L.P., J.-M.F., A.R.) and Facult? de M?decine (A.L.), Universit? de la M?diterran?e Aix?Marseille II; H?pital Sainte-Marguerite (C.P.-R.); Assistance Publique?H?pitaux de Marseille (G. Perrin); H?pital Ambroise Par? (J.-M.S.); and Centre d'Investigations Cliniques, Assistance Publique?H?pitaux de Marseille, INSERM 9502 (S.M.) ? all in Marseille; H?pital Pontchaillou, Rennes (A.G.); H?pital Saint Eloi, Montpellier (S.J.); H?pital Font-Pr?, Toulon (J.-M.A.); H?pital Jean Minjoz, Besan?on (D.P.); H?pital H?tel-Dieu, Clermont- Ferrand (J.-M.C.); Centre Hospitalier, Avignon (P.C.); H?pital Caremeau, N?mes (J.-Y.L.); H?pital de la Croix-Rousse, Lyon (C.G.); and H?pital de Cavale Blanche, Brest (G. Prat) ? all in France.
Address reprint requests to Dr. Papazian at Service de R?animation M?dicale, H?pital Nord, Chemin des Bourrely, 13009 Marseille, France, or at laurent.papazian@ap-hm.fr.
The ARDS et Curarisation Systematique (ACURASYS) study investigators are listed in the Appendix.
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------<cite cite="http://www.nejm.org/doi/full/10.1056/NEJMoa1005372?query=TOC"></cite>
[Source: The New England Journal of Medicine, free abstract: <cite cite="http://www.nejm.org/doi/full/10.1056/NEJMoa1005372?query=TOC">Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome ? NEJM</cite>. Edited.]
Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome
Laurent Papazian, M.D., Ph.D., Jean-Marie Forel, M.D., Arnaud Gacouin, M.D., Christine Penot-Ragon, Pharm.D., Gilles Perrin, M.D., Anderson Loundou, Ph.D., Samir Jaber, M.D., Ph.D., Jean-Michel Arnal, M.D., Didier Perez, M.D., Jean-Marie Seghboyan, M.D., Jean-Michel Constantin, M.D., Ph.D., Pierre Courant, M.D., Jean-Yves Lefrant, M.D., Ph.D., Claude Gu?rin, M.D., Ph.D., Gwena?l Prat, M.D., Sophie Morange, M.D., and Antoine Roch, M.D., Ph.D. for the ACURASYS Study Investigators
N Engl J Med 2010; 363:1107-1116
September 16, 2010
Background
In patients undergoing mechanical ventilation for the acute respiratory distress syndrome (ARDS), neuromuscular blocking agents may improve oxygenation and decrease ventilator-induced lung injury but may also cause muscle weakness. We evaluated clinical outcomes after 2 days of therapy with neuromuscular blocking agents in patients with early, severe ARDS.
Methods
In this multicenter, double-blind trial, 340 patients presenting to the intensive care unit (ICU) with an onset of severe ARDS within the previous 48 hours were randomly assigned to receive, for 48 hours, either cisatracurium besylate (178 patients) or placebo (162 patients). Severe ARDS was defined as a ratio of the partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen (FIO2) of less than 150, with a positive end-expiratory pressure of 5 cm or more of water and a tidal volume of 6 to 8 ml per kilogram of predicted body weight. The primary outcome was the proportion of patients who died either before hospital discharge or within 90 days after study enrollment (i.e., the 90-day in-hospital mortality rate), adjusted for predefined covariates and baseline differences between groups with the use of a Cox model.
Results
The hazard ratio for death at 90 days in the cisatracurium group, as compared with the placebo group, was 0.68 (95% confidence interval [CI], 0.48 to 0.98; P=0.04), after adjustment for both the baseline PaO2:FIO2 and plateau pressure and the Simplified Acute Physiology II score. The crude 90-day mortality was 31.6% (95% CI, 25.2 to 38.8) in the cisatracurium group and 40.7% (95% CI, 33.5 to 48.4) in the placebo group (P=0.08). Mortality at 28 days was 23.7% (95% CI, 18.1 to 30.5) with cisatracurium and 33.3% (95% CI, 26.5 to 40.9) with placebo (P=0.05). The rate of ICU-acquired paresis did not differ significantly between the two groups.
Conclusions
In patients with severe ARDS, early administration of a neuromuscular blocking agent improved the adjusted 90-day survival and increased the time off the ventilator without increasing muscle weakness.
(Funded by Assistance Publique?H?pitaux de Marseille and the Programme Hospitalier de Recherche Clinique R?gional 2004-26 of the French Ministry of Health; ClinicalTrials.gov number, NCT00299650.)
Source Information
From Assistance Publique?H?pitaux de Marseille Unit? de Recherche sur les Maladies Infectieuses et Tropicales ?mergentes (URMITE), Centre National de la Recherche Scientifique?Unit? Mixte de Recherche (CNRS-UMR) 6236 (L.P., J.-M.F., A.R.) and Facult? de M?decine (A.L.), Universit? de la M?diterran?e Aix?Marseille II; H?pital Sainte-Marguerite (C.P.-R.); Assistance Publique?H?pitaux de Marseille (G. Perrin); H?pital Ambroise Par? (J.-M.S.); and Centre d'Investigations Cliniques, Assistance Publique?H?pitaux de Marseille, INSERM 9502 (S.M.) ? all in Marseille; H?pital Pontchaillou, Rennes (A.G.); H?pital Saint Eloi, Montpellier (S.J.); H?pital Font-Pr?, Toulon (J.-M.A.); H?pital Jean Minjoz, Besan?on (D.P.); H?pital H?tel-Dieu, Clermont- Ferrand (J.-M.C.); Centre Hospitalier, Avignon (P.C.); H?pital Caremeau, N?mes (J.-Y.L.); H?pital de la Croix-Rousse, Lyon (C.G.); and H?pital de Cavale Blanche, Brest (G. Prat) ? all in France.
Address reprint requests to Dr. Papazian at Service de R?animation M?dicale, H?pital Nord, Chemin des Bourrely, 13009 Marseille, France, or at laurent.papazian@ap-hm.fr.
The ARDS et Curarisation Systematique (ACURASYS) study investigators are listed in the Appendix.
-
------<cite cite="http://www.nejm.org/doi/full/10.1056/NEJMoa1005372?query=TOC"></cite>