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.
Journal
Critical care medicine
ISSN: 1530-0293
Titre abrégé: Crit Care Med
Pays: United States
ID NLM: 0355501
Informations de publication
Date de publication:
01 07 2021
01 07 2021
Historique:
pubmed:
13
3
2021
medline:
14
9
2021
entrez:
12
3
2021
Statut:
ppublish
Résumé
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. Retrospective cohort study. Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). Intubated and mechanically ventilated ICU patients with acute respiratory distress syndrome (Berlin definition) admitted between January 2008 until June 2019. None. 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). 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.
Identifiants
pubmed: 33710031
doi: 10.1097/CCM.0000000000004951
pii: 00003246-202107000-00013
doi:
Substances chimiques
Neuromuscular Blocking Agents
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1137-1148Commentaires et corrections
Type : CommentIn
Type : CommentIn
Type : CommentIn
Informations de copyright
Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Déclaration de conflit d'intérêts
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.
Références
Luhr OR, Antonsen K, Karlsson M, et al. Incidence and mortality after acute respiratory failure and acute respiratory distress syndrome in Sweden, Denmark, and Iceland. The ARF study group. Am J Respir Crit Care Med. 1999; 159:1849–1861
Bellani G, Laffey JG, Pham T, et al.; LUNG SAFE Investigators; ESICM Trials Group. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016; 315:788–800
Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and Outcomes of Acute Lung Injury 2005. Available at: www.nejm.org . Accessed March 17¸ 2020
Forel JM, Roch A, Marin V, et al. Neuromuscular blocking agents decrease inflammatory response in patients presenting with acute respiratory distress syndrome. Crit Care Med. 2006; 34:2749–2757
Guervilly C, Bisbal M, Forel JM, et al. Effects of neuromuscular blockers on transpulmonary pressures in moderate to severe acute respiratory distress syndrome. Intensive Care Med. 2017; 43:408–418
Chanques G, Kress JP, Pohlman A, et al. Impact of ventilator adjustment and sedation-analgesia practices on severe asynchrony in patients ventilated in assist-control mode. Crit Care Med. 2013; 41:2177–2187
Beitler JR, Sands SA, Loring SH, et al. Quantifying unintended exposure to high tidal volumes from breath stacking dyssynchrony in ARDS: The BREATHE criteria. Intensive Care Med. 2016; 42:1427–1436
Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. 2008; 358:1327–1335
Segredo V, Caldwell JE, Matthay MA, et al. Persistent paralysis in critically ill patients after long-term administration of vecuronium. N Engl J Med. 1992; 327:524–528
Shehabi Y, Bellomo R, Reade MC, et al.; Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators; ANZICS Clinical Trials Group. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med. 2012; 186:724–731
Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018; 46:e825–e873
Shehabi Y, Riker RR, Bokesch PM, et al.; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit Care Med. 2010; 38:2311–2318
Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004; 291:1753–1762
Aragón RE, Proaño A, Mongilardi N, et al. Sedation practices and clinical outcomes in mechanically ventilated patients in a prospective multicenter cohort. Crit Care. 2019; 23:1–9
Papazian L, Forel JM, Gacouin A, et al.; ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010; 363:1107–1116
Moss M, Huang DT, Brower RG, et al. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med. 2019; 380:1997–2008
Alhazzani W, Belley-Cote E, Møller MH, et al. Neuromuscular blockade in patients with ARDS: A rapid practice guideline. Intensive Care Med. 2020; 46:1977–1986
Mascha EJ, Dalton JE, Kurz A, et al. Understanding the mechanism: Mediation analysis in randomized and nonrandomized studies. Anesth Analg. 2013; 117:980–994
Althoff FC, Agnihotri A, Grabitz SD, et al. Outcomes after endoscopic retrograde cholangiopancreatography with general anaesthesia versus sedation. Br J Anaesth. 2021; 126:191–200
Althoff FC, Wachtendorf LJ, Rostin P, et al. Effects of night surgery on postoperative mortality and morbidity : A multicentre cohort study. BMJ Qual Saf. 2020 Oct 7. [online ahead of print]
Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: The Berlin definition. JAMA. 2012; 307:2526–2533
Koenig HC, Finkel BB, Khalsa SS, et al. Performance of an automated electronic acute lung injury screening system in intensive care unit patients. Crit Care Med. 2011; 39:98–104
Afshar M, Joyce C, Oakey A, et al. A computable phenotype for acute respiratory distress syndrome using natural language processing and machine learning. AMIA Annu Symp Proc. 2018; 2018:157–165
Lee H, Herbert RD, McAuley JH. Mediation analysis. JAMA. 2019; 321:697–698
Imai K, Keele L, Tingley D, et al. Unpacking the black box of causality: Learning about causal mechanisms from experimental and observational studies. Am Polit Sci Rev. 2011; 105:765–789
Shrout PE, Bolger N. Mediation in experimental and nonexperimental studies: New procedures and recommendations. Psychol Methods. 2002; 7:422–445
Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011; 46:399–424
Fritz MS, Mackinnon DP. Required sample size to detect the mediated effect. Psychol Sci. 2007; 18:233–239
Villar J, Ambrós A, Soler JA, et al.; Stratification and Outcome of Acute Respiratory Distress Syndrome (STANDARDS) Network. Age, PaO2/FIO2, and plateau pressure score: A proposal for a simple outcome score in patients with the acute respiratory distress syndrome. Crit Care Med. 2016; 44:1361–1369
Hager DN, Dinglas VD, Subhas S, et al. Reducing deep sedation and delirium in acute lung injury patients: A quality improvement project. Crit Care Med. 2013; 41:1435–1442
Azoulay E, Citerio G, Bakker J, et al. Year in review in intensive care medicine 2013: II. Sedation, invasive and noninvasive ventilation, airways, ARDS, ECMO, family satisfaction, end-of-life care, organ donation, informed consent, safety, hematological issues in critically ill patients. Intensive Care Med. 2014; 40:305–319