The information on this website is not intended for diagnosis or treatment. Please consult your physician for health concerns.

+90 850 321 50 00

Neuromuscular Blockade in ARDS — Cisatracurium Use and Evidence

Role of neuromuscular blockade during the first 48 hours of severe ARDS for patient-ventilator synchronization and VILI reduction.

Written by: Saygı Hospital Health Guide Editorial Board
Published: · Last updated:

This content is for general information; please consult your physician for diagnosis and treatment.

References (2)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Göğüs Hastalıkları department. Book Appointment →

What is Neuromuscular Blockade in ARDS — Cisatracurium Use and Evidence?

Neuromuscular blockade (NMB) is used in severe ARDS to control patient-ventilator asynchrony and spontaneous-breathing-effort-related harmful transpulmonary pressure (P-SILI). Cisatracurium (Nimbex) — non-depolarizing, Hofmann elimination (no accumulation in organ failure), low histamine release — is the preferred agent.

ACURASYS (2010, NEJM) — French multi-center RCT of 340 patients with P/F <150 severe ARDS; 48-hour cisatracurium bolus: 90-day mortality 31.6% vs placebo 40.7% (adjusted HR 0.68, p=0.04). Mechanism: deep sedation + NMB eliminates patient-ventilator asynchrony, reducing barotrauma/volutrauma.

ROSE (2019, NEJM) — US multi-center RCT of 1006 patients with P/F <150 ARDS; 48-hour cisatracurium vs light sedation + spontaneous breathing: no mortality difference. Conclusion: with a light-sedation strategy, the NMB advantage disappears; however, benefit may persist in the very-severe-hypoxemia subgroup (P/F <100).

SSC 2021 recommends: not routine, but consider 48 hours of cisatracurium in selected severe ARDS — especially with asynchrony, high plateau pressure, and before prone positioning. NMB beyond 48 hours substantially raises ICU-AW risk.

Symptoms

Severe ARDS + P/F <150 + deep sedation insufficient — persistent patient-ventilator asynchrony
High plateau pressure >30 or ΔP >15 — NMB may be added to restrict tidal volume
Before prone positioning — deep sedation + NMB are critical during the turn
High oxygen consumption — sepsis, fever, agitation + ARDS → NMB lowers O2 demand
Status asthmaticus and severe COPD exacerbation with dynamic hyperinflation

Risk Factors

Prolonged NMB (>48-72 hours) — markedly increases ICU-AW (critical-illness myopathy) risk
Concomitant high-dose steroids (methylprednisolone >1 mg/kg/day) — CIM risk multiplies; muscle strength loss is rapid
Continuous infusion vs bolus — bolus is preferred (titration, lower cumulative dose, easier awareness assessment)
Awareness — inadequate sedation combined with NMB risks paralyzing an insufficiently sedated patient; confirm with RASS -4 or BIS 40-60
Elimination profile — cisatracurium Hofmann (safe in organ failure); vecuronium hepatic; rocuronium hepatic (decreased renal); succinylcholine depolarizing (severe side effects, emergency use)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Severe ARDS + asynchrony + high plateau + inadequate deep sedation — indication for NMB
  • Reassess after 48 hours — consider stopping NMB (most patients); balance ICU-AW risk
  • When deciding on prone positioning — NMB is needed during the positional change

Treatment Methods

01
Prioritize sedation — before NMB, ensure deep sedation: propofol or midazolam + opioid; target RASS -4 to -5, BIS 40-60
02
Cisatracurium — bolus 0.15-0.2 mg/kg IV followed by continuous infusion 1-3 mcg/kg/min (ACURASYS protocol: bolus + infusion day 1, bolus day 2, stop day 3)
03
Train-of-Four (TOF) monitoring — ulnar nerve, target very weak response (1-2/4 twitches); fully 0 suggests overdose. Essential with prolonged NMB
04
Continuous sedation + analgesia — during NMB, assessment of spontaneous breathing/awareness is impossible; ensure continuous sedation/analgesia to prevent awareness
05
Stop after 48 hours — discontinue NMB; spontaneous respiration returns (cisatracurium via Hofmann elimination); sedation can be continued or lightened
06
Avoid prolonged NMB (>72 hours) — if clinically necessary, consider daily NMB holidays to assess muscle function (can the patient trigger breaths)

Which Department to Visit?

You can visit our Göğüs Hastalıkları department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

Learn About Göğüs Hastalıkları Department

Let us help you

You can make an appointment with our specialists or contact us for your concerns.

Book AppointmentContact Us

Related Health Topics

Other articles from the same department you may want to explore.

Asthma

Göğüs Hastalıkları

Asthma is characterized by wheezing, coughing and shortness of breath attacks; with proper treatment it can be kept under control.

COPD (Chronic Obstructive Pulmonary Disease)

Göğüs Hastalıkları

COPD is an irreversible lung disease characterized by shortness of breath and chronic cough; quitting smoking slows its progression.

Pneumonia

Göğüs Hastalıkları

Pneumonia presents with high fever, cough and shortness of breath; the vast majority recover with appropriate antibiotic treatment.

Tuberculosis (TB)

Göğüs Hastalıkları

Tuberculosis presents with weeks-to-months of cough, fever, and night sweats; early diagnosis and treatment lead to full recovery.

Pleural Effusion

Göğüs Hastalıkları

Pleural effusion is the accumulation of excess fluid in the pleural space, resulting from imbalances in fluid production and removal, and represents a manifestation of diverse cardiopulmonary, infectious, and malignant disorders.

Pneumothorax

Göğüs Hastalıkları

Pneumothorax is the presence of air in the pleural space resulting in partial or complete lung collapse, classified as spontaneous (primary/secondary), traumatic, or iatrogenic, with tension pneumothorax representing a life-threatening emergency.

Bronchitis (Acute and Chronic)

Göğüs Hastalıkları

Acute bronchitis is mostly viral and resolves spontaneously, while chronic bronchitis is a smoking-related component of COPD.

Bronchiectasis

Göğüs Hastalıkları

Bronchiectasis is a chronic respiratory disease characterized by permanent, abnormal dilation of bronchi with associated destruction of muscular and elastic components of airway walls, resulting in impaired mucociliary clearance and recurrent infection.

Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.