ICU Journal Reading 20190812 存檔版
ICU Journal Reading 20190812 存檔版
ICU Journal Reading 20190812 存檔版
ER R2 林林 毅
To Fight ARDS
Limiting iatrogenicity -Low tidal volume
-Prone position
-Neuromuscular
Blockade ???
In severe ARDS,
early administration of neuromuscular blocking agent
improved survival and increased the time off the ventilator
Dyssynchrony
Breath Stacking
呼吸堆疊
Criticism on ACURASYS
• Under-powered
(N=340, need 885 to achieve 80% statistical power)
[2] Chanques G, Kress JP, Pohlman A, Patel S, Poston J, Jaber S, Hall JB. Impact of ventilator adjustment and sedation-analgesia practices on severe
asynchrony in patients ventilated in assist-control mode. Crit Care Med 2013;41(9):2177–2187.
• Better understanding of
ventilator setting
•Key Differences
-Lighter sedation
-Higher PEEP strategies
-Conservative fluid strategies
-3, 6, 12 months follow-up
Jan. 2016-Apr. 2018
501 505
Primary End Point In-hospital Death within 90 days
Organ Dysfunction
Daysot in Hospitals
Survival
Disability
3, 6, 12 months
Health-related QOL
Return to Work
Recall of Paralysis
Barotrauma
P=0.05
P=0.047
還活著
能回家
Primary End Point
In-hospital
Death 213(42.5±2.2) 216(42.8±2.2) -0.3 (-6.4 to 5.9) 0.93
by day 90(%)
No Significant Difference
in 90 Day Mortality
Secondary End Points
Intervention Between-Group
Control Group
Group Difference
(N=505)
(N=501) (95%CI)
In-hospital
Death 184(36.7) 187(37.0) -0.3(-6.3 to 5.7)
by day 28(%)
Days Free of
9.6±10.4 9.9±10.9 -0.3(-1.7 to 1.0)
MV on day 28
Days Not in ICU
9.0±9.4 9.4±9.8 -0.4(-1.6 to 0.8)
on Day 28
Days Not in
Hospital on Day 5.7±7.8 5.9±8.1 -0.2(-1.1 to 0.8)
28
No Significant Differences
Safety End Points
肢體weakness
What’s the Differences
• Higher PEEP strategy in both groups
ACURASYS Trial
Intervention Control
ROSE Trial
Intervention Control
ACURASYS ROSE
Prone position
Intervention Control
ACURASYS 50(28%) 47(29%)
• 只能single blinding,可能主觀的影響後續運動功能的評估
及adverse events report
Conclusion
對於使⽤用現今主流
High PEEP Low Tidal Volume Strategy
with Light Sedation
Moderate to Severe ARDS病患
早期使⽤用Continuous NMBA
不會
改善90天內Mortality
So…
Early Paralytic Agents for ARDS?
YES No
Or Sometimes
Breathing Stacking
• Difficult to recognize
Intervention Control
NMBA
ACURASYS Deep Sedation
Deep Sedation
NMBA
ROSE Light Sedation
Deep Sedation
[1] Bourenne J. Variability of reverse triggering in deeply sedated ARDS patients. Intensive Care Med. 2019 May;45(5):725-726.
[2] Epstein SK. How often does patient-ventilator asynchrony occur and what are the consequences? Respir Care 2011;56(1):25–38.
Lessons Learned from the Trial
• Routine use of NMBA is not recommended
• 出現Dyssynchrony,調整呼吸器跟sedation仍無法改善時
NMBA可能有幫助