Neuromuscular blockade in patients with ARDS: a rapid practice guideline.

The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) is to formulate an evidence-based guidance for the use of neuromuscular blocking agents (NMBA) in adults with acute respiratory distress syndrome (ARDS). The panel comprised 20 international clinical experts from 12 countries, and 2 patient representatives. We adhered to the methodology for trustworthy clinical practice guidelines and followed a strict conflict of interest policy. We convened panelists through teleconferences and web-based discussions. Guideline experts from the guidelines in intensive care, development, and evaluation Group provided methodological support. Two content experts provided input and shared their expertise with the panel but did not participate in drafting the final recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence and grade recommendations and suggestions. We used the evidence to decision framework to generate recommendations. The panel provided input on guideline implementation and monitoring, and suggested future research priorities. The overall certainty in the evidence was low. The ICM-RPG panel issued one recommendation and two suggestions regarding the use of NMBAs in adults with ARDS. Current evidence does not support the early routine use of an NMBA infusion in adults with ARDS of any severity. It favours avoiding a continuous infusion of NMBA for patients who are ventilated using a lighter sedation strategy. However, for patients who require deep sedation to facilitate lung protective ventilation or prone positioning, and require neuromuscular blockade, an infusion of an NMBA for 48 h is a reasonable option.

Sedation practices in a cohort of critically ill patients receiving prolonged mechanical ventilation.

BACKGROUND: The aim of this paper was to describe type and amount of sedatives, opioid analgesics and anti- psychotics administered to critically ill patients receiving prolonged mechanical ventilation and identify patient-specific factors associated with their administration. METHODS: Retrospective cohort study of adult patients mechanically ventilated for ≥14 days over a two-year period. RESULTS: The majority of patients (88%) received lorazepam for sedation (median 14-day dose 168 mg, IQR 25-606). Morphine (median 14-day dose 125 mg, IQR 0-850) and fentanyl (median 14-day dose 2032 mcg, IQR 175-15346) were administered with relative equal frequency. Only 48% of the cohort received anti-psychotics during the first 14 days. Age was inversely associated with cumulative dose of lorazepam equivalents (ratio 0.97; 95% CI 0.95-0.99), propofol (ratio 0.93; 95% CI 0.89-0.96), and morphine equivalents (ratio 0.97; 95% CI 0.96-0.98). Substance abuse was associated with cumulative dose of lorazepam (ratio 3.37; 95% CI 1.14-8.21) and morphine equivalents (ratio 3.09; 95% CI 1.48-6.44). Ethanol abuse was associated with >50% lower cumulative dose of morphine equivalents (ratio 0.47; 95% CI 0.25-0.87). CONCLUSION: In critically ill patients receiving prolonged ventilation, history of substance abuse predicted a 3-fold increase in 14-day cumulative dose of sedatives and opioids used. Conversely, older age was associated with decreased use of sedatives and opioids and history of alcohol abuse was only associated with decreased opioid use. Overall, patients receiving prolonged mechanical ventilation appeared to consume high cumulative doses of sedatives and opioids, with less frequent use of antipsychotics. Accounting for patient characteristics may help identify individuals with varying sedative needs.