viernes, 10 de enero de 2014

REMI 1928E. Neuromuscular blocking agents in severe sepsis patients

[Versión en español]
      
Original Article: Steingrub JS, Lagu T, Rothberg MB, Nathanson BH, Raghunathan K, Lindenauer PK. Treatment with neuromuscular blocking agents and the risk of in-hospital mortality among mechanically ventilated patients with severe sepsis. Crit Care Med 2014; 42(1): 90-96. [Summary] [Related Articles]
          
Introduction: Recent studies have shown the potential benefit of using continuous muscle relaxation for 48 hours in the early stages of Acute Respiratory Distress Syndrome (ARDS) [1, 2].  This beneficial effect may occur because it facilitates the application of a protective ventilatory strategy and by decreasing ventilator-patient asynchrony during this period, but its routine use remains controversial [3]. In the present study the authors explore the relationship between treatment with neuromuscular blocking agents (NMBA) and prognosis in ventilated patients with severe sepsis, regardless of the existence of ARDS.
      
Abstract: The study analyzed a cohort of patients who required mechanical ventilation within 48 hours of hospital admission with the diagnosis of severe sepsis and explore by the method of "propensity score matching" the relationship of NMBA use on mortality. Patients were selected from a prospective database between 2004 and 2006 and including 7,864 patients, of whom 1,818 received NMBA. The main finding of this study is that the use of NMBA in this population was associated with a reduced risk of in-hospital mortality (risk ratio 0.88, 95% CI 0.80 to 0.96), absolute risk reduction 4.3% (95% CI -11.5% to -1.5%).
      
Comment: In a recent systematic review on the use of cisatracurium infusion in ARDS patients (three studies and 431 patients) a significant reduction in mortality was observed, although no effects on the total duration of mechanical ventilation or incidence of neuromuscular weakness were noted [4, 5]. However the number of ARDS patients studied is not very high and some controversy remains about its routine use [5]. To my knowledge, the present study is really confusing, with a very complex statistical design that looks more like a game than a mathematical interpretation of what happens in the clinical practice. To adequately interpret this study it must be taken into account: the initial database includes about 71,000 patients, but only 7,864 are analyzed, patients receiving NMBA were younger (62 and 68), and other potentially prognostic factors such as comorbidities are unknown. The database included patients receiving any muscle relaxant (atracurium, cisatracurium, doxacurium, mivacurium, pancuronium, rocuronium, or vecuronium), even receiving only one dose for 1 day, and not explains nothing of something as basic as the ventilation mode, or the indication of relaxation. It certainly is an interesting study, but its results need to be interpreted with great caution and could serve to generate hypotheses but  not to guide the treatment of patients.
     
Federico Gordo Vidal
Hospital Universitario del Henares, Coslada, Madrid.
© REMI, http://medicina-intensiva.com. Enero 2014.
      
Links:
  1. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, Constantin JM, Courant P, Lefrant JY, Guérin C, Prat G, Morange S, Roch A. Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome. N Engl J Med 2010; 363: 1107-1116. [PubMed]
  2. Bloqueantes neuromusculares en la fase precoz del SDRA. Palencia Herrejón E. [REMI 2010; 10(9): 1554]
  3. Bloqueo neuromuscular con cisatracurio en el SDRA precoz: no digas nunca jamás, pero siempre tampoco. Editorial. Gordo Vidal F, Garnero AJ. [REMI 2010; 10 (9): E69]
  4. Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Alhazzani W, Alshahrani M, Jaeschke R, Forel JM, Papazian L, Sevransky J, Meade MO. Crit Care 2013, 17: R43. [PubMed]
  5. Bloqueo neuromuscular en el SDRA: revisión sistemática. Molina Lobo R. [REMI 2013; 13(4): 1842]
Búsqueda en PubMed:
  • Plain LanguageNeuromuscular Blockers in ARDS
  • Sintax: Neuromuscular Blockers AND Acute Respiratory Distress Syndrome
  • [Results]
                

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