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The effect of neuromuscular blocking agents use in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION
With the latest addition from Re-evaluation of Systemic Early Neuromuscular Blockade (ROSE) trial result, the question of mortality benefit from neuromuscular blocking agents (NMBAs) in different studies, remained unanswered. We hypothesize that NMBAs use in moderate to severe acute respiratory distress syndrome (ARDS) does not influence intensive care unit (ICU) mortality.


EVIDENCE ACQUISITION
Pubmed, Embase and the Cochrane Library were searched for randomized controlled trials (RCTs) related to NMBAs infusion in patients with ARDS. The primary outcome was ICU mortality. Secondary outcomes were mortality at day 28 and day 90, oxygenation response to NMBA, ICU length of stay (LOS), ICU Acquired weakness (ICU-AW) and ventilator-free days (VFDs). Meta-analysis was conducted to re-evaluate the effect of NMBAs on patients with ARDS with all randomised controlled trials available.


EVIDENCE SYNTHESIS
NMBAs infusion was associated with reduced ICU mortality [relative ratio (RR) : 0.69; 95% confidence-interval (CI): 0.55-0.88; I2 = 0 %], but not 28 days mortality (RR: 0.76; 95% CI: 0.57-1.0; I2 = 49%) and 90-day mortality (RR: 0.87; 95% CI: 0.70-1.08; I2 = 46%). NMBA use was not associated with increased risk of ICU-AW (RR, 1.21; 95% CI, 0.84 to 1.76; I2 = 34%).


CONCLUSIONS
Early 48-hour NMBAs infusion in patients with moderate to severe ARDS was associated with reduced ICU mortality without improvement in oxygenation, VFDs, 28-day and 90-day mortality. It did not contribute significantly to ICU-AW. Based on these results, NMBAs infusion is recommended for moderate to severe ARDS for its short-term benefit in early phase of disease. Prolonged use of NMBAs beyond 48 hours requires further study.