(999) Neuromuscular Blocking Agents for Acute Respiratory Distress Syndrome: A Meta-Analysis

Introduction: Cisatracuriumv (Cis), a non-steroidal neuromuscular blocking agent, has been used to examine the role of NMBAs for acute respiratory distress syndrome (ARDS). However, emerging studies have also examined vecuronium (Vec), a steroidal NMBA, which is potentially associated with ICU-acquired weakness (ICU-AW). Herein, we updated a meta-analysis on the efficacy of NMBA use for adults with ARDS and examined the impact of NMBA type on outcomes.

Methods: We searched Medline, Embase, and CENTRAL through January 2022 for randomized controlled trials in which the intervention was the use of NMBAs in mechanically-ventilated adult patients with moderate-to-severe ARDS. Our primary outcomes were mortality truncated to day 28 and the incidence of ICU-AW. Other outcomes included mortality at day 90, the incidence of barotrauma during mechanical ventilation, ICU-free days at day 28, and ventilation-free days at day 28. We pooled the data using a random-effects model.

Results: We included 10 randomized controlled trials involving 1828 participants. Cis and Vec were examined in 6 studies and 4, respectively. The use of NMBAs was associated with a decreased mortality truncated to day 28 (risk ratio [RR] 0.69; 95% CI 0.54 to 0.90; 10 trials), while it had no significant impact on the incidence of ICU-AW (RR 1.16; 95% CI 0.99 to 1.37; 5 trials). NMBA use was not associated with a reduction in mortality at day 90 (RR 0.96; 95% CI 0.59 to 1.55; 4 trials), ventilation-free days (mean difference [MD] 0.56 days; 95% CI -0.46 to 1.56; 6 trials), or ICU-free days (MD 0.11 days; 95% CI -0.92 to 1.13; 4 trials), while it was associated with a reduced incidence of barotrauma (RR 0.55; 95% CI, 0.35 to 0.85; 5 trials). ICU-AW and barotrauma were examined with Cis alone; there was no difference in the remaining outcomes by NMBA type.

Conclusions: Our updated meta-analysis reconfirmed that NMBA use could decrease short-term mortality and barotrauma in patients with moderate-to-severe ARDS. However, the impacts of NMBA use on long-term outcomes and of its type on ICU-AW still need to be investigated. Such information will trigger studies on the use of steroidal NMBAs for ARDS as well as on the long-term outcomes after treatment with NMBAs for ARDS.