SPECIAL ARTICLE<\/p>\n\n\n\n
Neuromuscular blocking agents (NMBAs) show potential benefits on mortality and other complications of acute respiratory distress syndrome (ARDS) in adult patients. Evidence-based decisions and processes ensure appropriate use of neuromuscular blockade in adult patients with ARDS.<\/p>\n\n\n\n
The objective of these guidelines was to develop evidence-based recommendations for the administration of NMBAs in critically ill adult patients with ARDS.<\/p>\n\n\n\n
The American College of Critical Care Medicine Board convened a 21-member multidisciplinary panel of experts in critical care medicine, nursing, respiratory therapy, pharmacology, surgery, neurology, and anesthesiology. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guidelines development including task force selection and voting.<\/p>\n\n\n\n
The panel members identified and formulated five Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and assessed the certainty of the evidence using the GRADE methodology. We used the GRADE evidence-to-decision framework to formulate the recommendations.<\/p>\n\n\n\n
The panel generated two conditional recommendations. One recommendation is to use NMBAs in adults with ARDS with Pao2<\/sub>\/Fio2<\/sub>\u00a0less than 150. For the other recommendations, there was equipoise in the recommendation for and against using titratable vs. fixed-dose NMBA dosing, a monitoring-based strategy for assessing depth of sedation and analgesia in adults with ARDS before initiating or while receiving neuromuscular blockade, and administration of NMBAs for patients who are proned, due to overall lack of evidence in critically ill patients and due to considerations of patient safety and experience concerns.<\/p>\n\n\n\n TABLE 1. - Recommendations<\/em><\/p>\n\n\n\n TABLE 2. - Strength of Recommendation<\/em><\/p>\n\n\n\n TABLE 3. - Research Priorities<\/em><\/p>\n\n\n\n These guidelines provide additional perspectives on the use of NMBA in patients with ARDS, recognizing that institutional and patient-specific considerations must help to guide the decision-making process.<\/p>\n","protected":false},"excerpt":{"rendered":" SPECIAL ARTICLE Society of Critical Care Medicine Guide […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[25,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30525"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=30525"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30525\/revisions"}],"predecessor-version":[{"id":30526,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30525\/revisions\/30526"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=30525"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=30525"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=30525"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}No.<\/th> Recommendation<\/th> Strength<\/th> Certainty of Evidence<\/th><\/tr><\/thead> 1<\/td> We suggest using NMBAs over not using NMBAs in adults with ARDS with Pao 2<\/sub>\/Fio 2<\/sub> < 150 who are persistently hypoxemic and\/or not achieving mechanical ventilation targets on sedation<\/td> Conditional for<\/td> Low<\/td><\/tr> 2<\/td> We suggest using either a fixed-dose strategy without monitoring depth of neuromuscular blockade, or a titration-based strategy by monitoring depth of neuromuscular blockade for adults with ARDS<\/td> Conditional for<\/td> Very low<\/td><\/tr> 3<\/td> We suggest using either a scale-based evaluation or nonscale-based evaluation for depth of analgesia and sedation before initiating NMBA for adult patients with ARDS<\/td> Conditional for<\/td> Very low<\/td><\/tr> 4<\/td> We suggest using either a monitoring-based strategy or no monitoring of depth of analgesia and sedation in adults with ARDS who are receiving NMBAs<\/td> Conditional for<\/td> Very low<\/td><\/tr> 5<\/td> We suggest either administering neuromuscular blockade or not administering neuromuscular blockade in adult patients who are proned for ARDS<\/td> Conditional for<\/td> Very low<\/td><\/tr><\/tbody><\/table> Stakeholders<\/th> Strong Recommendation<\/th> Conditional Recommendation<\/th><\/tr><\/thead> Patients<\/td> Nearly all individuals in a given situation would want the recommended intervention; only a small proportion would not<\/td> The majority of individuals in a given situation would want the suggested recommendation, but a significant minority would not<\/td><\/tr> Clinicians<\/td> Nearly all patients should receive the recommended intervention. Adherence to this recommendation could potentially be used as a quality indicator<\/td> Different choices will be appropriate for different patients, and clinicians should expect to spend more time on decision-making, taking into account a patient\u2019s specific circumstances, preferences and values. Policy-making will require substantial debate and input from many stakeholders<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n Topic<\/th> Research Priorities<\/th><\/tr><\/thead> Neuromuscular blockade administration<\/td> Optimal trigger for initiating NMBA (e.g., relative to course early vs. late, relative to depth of sedation, cutoff based on Pao 2<\/sub>\/Fio 2<\/sub> ratios, relative to the presence of pulmonary mechanics or relative to the presence of right ventricular dysfunction, or use of multimodality scores like Murray score)<\/td><\/tr> Efficacy of different NMBAs<\/td><\/tr> Interplay between different modes of mechanical ventilation and use of NMBAs<\/td><\/tr> Reproducibility of results evaluating NMBAs in ARDS across different global population subsets (high- vs. low-resource critical care settings, interplay between patent-related factors, age, gender, ethnicity, and ARDS et Curarisation Systematique\/Prevention and Early Treatment of Acute Lung Injury-Reevaluation of Systemic Early Neuromuscular Blockade (ACURARYS)\/Prevention and Early Treatment of Acute Lung Injury-Reevaluation of Systemic Early Neuromuscular Blockade (PETAL-ROSE) restricted to France and the United States)<\/td><\/tr> Healthcare utilization metrics vs. patient-reported clinical outcomes with regard to analgesia and sedation practices (less ICU-acquired weakness may be meaningful for the patient compared with two extra days of hospitalization)<\/td><\/tr> Titration\/dosing of NMBAs<\/td> Mechanism of benefit of NMBAs (could impact dosing strategy)<\/td><\/tr> Influence of dosing strategy\u2014complete vs. deep block on adverse events and outcomes<\/td><\/tr> Target for depth of blockade when using quantitative monitoring (ventilator synchrony, TOF)<\/td><\/tr> Optimal metrics on peripheral nerve stimulation monitoring\u2014TOF ratio, TOF count, post-tetanic count, frequency, goals, quality of monitoring, etc<\/td><\/tr> Dose with vs. without steroids, need to change dose for prolonged durations<\/td><\/tr> The benefit of NMBA may be a function of ARDS phenotype in patients with increased respiratory system elastance, an area for future research<\/td><\/tr> Patient-centered NMBA dosing based on the effect of NMBA blockade based on age, sex, pregnancy, coexisting renal or hepatic disease and by coexisting drugs like calcium channel blockers, antiarrhythmic agents, steroids, electrolyte imbalance, and aminoglycoside antibiotics<\/td><\/tr> Scale-based strategies for clinical evaluation of depth of analgesia and sedation<\/td> Differences in the specific drugs used for analgesia and sedation<\/td><\/tr> Drug dosing strategies, use of single vs. combination drugs for analgesia and sedation<\/td><\/tr> Analgesia and sedation monitoring strategy for goals before blockade<\/td><\/tr> Monitoring depth of analgesia\/sedation<\/td> Differences in the specific drugs used for analgesia and sedation<\/td><\/tr> Drug dosing strategies, use of single vs. combination drugs for analgesia and sedation<\/td><\/tr> Analgesia and sedation monitoring strategy for goals before blockade<\/td><\/tr> Comparing the efficacy and accuracy of different monitoring tools, recognizing that monitoring raises different issues in the ICU vs. operating room<\/td><\/tr> Healthcare utilization metrics vs. patient-reported clinical outcomes with regard to analgesia and sedation practices<\/td><\/tr> Evaluation of specific outcomes deemed important for but not evaluated in the current literature (e.g., quality of life, cognitive function, psychologic outcomes)<\/td><\/tr> Patients who are proned for ARDS<\/td> NMBA first or prone first?<\/td><\/tr> If already paralyzed and now considering proning\u2014when to prone patients, which patients to prone, and how long to prone<\/td><\/tr> Factors influencing outcomes (e.g., level of sedation and use of prone positioning)<\/td><\/tr><\/tbody><\/table> Conclusions: <\/h3>\n\n\n\n