Continuous Infusion Versus Intermittent Boluses of Cisatracurium in the Early Management of Pediatric Acute Respiratory Distress Syndrome: A Multicenter, Randomized Controlled Trial

Abstract

Objectives

Pediatric acute respiratory distress syndrome (PARDS) is a critical condition associated with considerable morbidity and mortality. Trials in adults showed controversial results about neuromuscular blocking agents (NMBAs) use in adult acute respiratory distress syndrome. With limited data in PARDS, we sought to compare the outcomes of continuous cisatracurium infusion versus intermittent bolus administration in children with PARDS.

Methods

This multicenter randomized controlled study was performed on patients with PARDS. Enrolled patients were categorized into: group I: patients treated with intermittent boluses of cisatracurium and group II: patients treated with intravenous infusion of cisatracurium for 24 h. The primary outcome was the duration on mechanical ventilator (MV). Additional results included changes in ventilatory parameters, and length of pediatric intensive care unit (PICU) stay.

Results

Group II was associated with a significantly higher extubation from MV compared to group I, after accounting for death as a competing event. This association was confined to moderate-to-severe PARDS (subdistribution hazard ratio (SHR) 3.25, 95% CI 1.69–6.25, p < 0.001) and not observed in mild PARDS. Similar with earlier PICU discharge, with stronger effect in moderate-to-severe disease (SHR 3.16, 95% CI 1.64–6.11, p < 0.001). By day 7, patients with moderate-to-severe PARDS in group II showed lower fraction of inspired oxygen, mean airway pressure, and oxygenation index.

Conclusions

In PARDS, cisatracurium infusion was associated with better oxygenation, earlier extubation from MV and shorter PICU stay compared to intermittent boluses, with benefits limited to moderate-to-severe disease. Outcomes were similar in mild PARDS.