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    ICU Journal Reading 20190812 存檔版

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    林毅
    This document summarizes a clinical trial that evaluated the early use of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS). The trial found no significant difference in 90-day mortality between patients receiving early NMBA plus light sedation compared to light sedation alone. Secondary outcomes like ventilator-free and ICU-free days were also not significantly different. The trial demonstrated that for patients receiving a high PEEP, low tidal volume strategy with light sedation, early continuous NMBA did not improve outcomes. However, NMBA may still be beneficial in cases of severe patient-ventilator dyssynchrony not improved by adjusting ventilator settings or sed

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    ICU Journal Reading 20190812 存檔版

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    林毅
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    This document summarizes a clinical trial that evaluated the early use of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS). The trial found no significant difference in 90-day mortality between patients receiving early NMBA plus light sedation compared to light sedation alone. Secondary outcomes like ventilator-free and ICU-free days were also not significantly different. The trial demonstrated that for patients receiving a high PEEP, low tidal volume strategy with light sedation, early continuous NMBA did not improve outcomes. However, NMBA may still be beneficial in cases of severe patient-ventilator dyssynchrony not improved by adjusting ventilator settings or sed

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    Paralyzing ARDS patients

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    This document summarizes a clinical trial that evaluated the early use of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS). The trial found no significant difference in 90-day mortality between patients receiving early NMBA plus light sedation compared to light sedation alone. Secondary outcomes like ventilator-free and ICU-free days were also not significantly different. The trial demonstrated that for patients receiving a high PEEP, low tidal volume strategy with light sedation, early continuous NMBA did not improve outcomes. However, NMBA may still be beneficial in cases of severe patient-ventilator dyssynchrony not improved by adjusting ventilator settings or sed

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    26 views26 pages

    ICU Journal Reading 20190812 存檔版

    Uploaded by

    林毅
    This document summarizes a clinical trial that evaluated the early use of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS). The trial found no significant difference in 90-day mortality between patients receiving early NMBA plus light sedation compared to light sedation alone. Secondary outcomes like ventilator-free and ICU-free days were also not significantly different. The trial demonstrated that for patients receiving a high PEEP, low tidal volume strategy with light sedation, early continuous NMBA did not improve outcomes. However, NMBA may still be beneficial in cases of severe patient-ventilator dyssynchrony not improved by adjusting ventilator settings or sed

    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    of 26

    Paralyzing Patients

    with ARDS…or NOT?

    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)

    • No monitor on patient-ventilator synchrony



    May be as low as 30%[1]

    • Other means to avoid asynchrony[2]



    -adjust ventilator setting

    • Concerns about NMBA


    [1] Epstein SK. How often does patient-ventilator asynchrony occur and what are the consequences? Respir Care 2011;56(1):25–38.

    [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

    • Better evidence of



    prone position

    • Current practice promotes



    lighter sedation

    • Limited data of



    long term outcome
    May 19, 2019

    Reevaluate Of Systemic Early Neuromuscular Blockage Trial


    Trial Design
    •Based on ACURASYS Trial

    -Same NMBA regimen

    •Key Differences

    -Lighter sedation

    -Higher PEEP strategies

    -Conservative fluid strategies

    -3, 6, 12 months follow-up
    Jan. 2016-Apr. 2018

    MV via ETT less than 48 hrs


    - PF ratio <150
    - PEEP>8 cmH2O
    - Bil. pulmonary opacities

    非積液、非塌陷、非tumor
    - 無法⽤用HF或fluid overload

    解釋的喘
    1008
    15mg bolus + 37.5mg/hr

    Nimbex+Deep Sedation Light Sedation


    Ramsay 6 502 506 Ramsay 2-3

    Low tidal volume + High PEEP


    Suggest Prone after 12 hrs
    Allow Nimbex bolus 20mg
    Control 48 hrs

    501 505
    Primary End Point In-hospital Death within 90 days
    Organ Dysfunction

    In-hospital Death within 28 days

    Days Free of Organ Dysfunction

    Secondary End Points


    Days Not in ICU

    Days Free of Ventilator

    Daysot in Hospitals
    Survival

    Disability

    3, 6, 12 months
    Health-related QOL

    End Points Pain

    Return to Work
    Recall of Paralysis

    ICU Acquired Weakness Till 28 Days

    Safety End Points Limitation of Physical Activity

    New-onset Afib or SVT

    Barotrauma
    P=0.05
    P=0.047
    還活著

    能回家
    Primary End Point

    Intervention Control Between-Group


    P
    Group Group Difference
    value
    (N=501) (N=505) (95%CI)

    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

    PEEP(cmH2O) 9.2±3.2 9.2±3.5

    ROSE Trial

    Intervention Control

    PEEP(cmH2O) 12.6±3.6 12.5±3.6


    What’s the Differences
    • Lighter sedation in control group

    Sedation in Control Group

    ACURASYS ROSE

    Ramsey Sedation Scale 6 2-3

    • May explain the lower CV adverse event in control group



    >>Because less sedated
    What’s the Differences
    • Prone position less used in ROSE trial, but more realistic

    Prone position
    Intervention Control
    ACURASYS 50(28%) 47(29%)

    ROSE 84(16.8%) 75(14.9%)

    • Early continuous NMBA



    More effective with prone position?
    Limitations
    • Enroll前就⽤用過NMBA的⼈人被exclude

    可能會miss掉本來來就最容易易受益的族群

    • 沒有measure ventilator dyssynchrony

    • 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

    • Increase with deeper sedation[1]

    • Occur in 30% ARDS[2]

    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

    • Try not to aim for an uniform strategy in ARDS



    

    NMBA treats dyssynchrony

    NOT ARDS

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