COMMENTARY

Cisatracurium Versus Vecuronium for Acute Respiratory Distress Syndrome

Gregory S. Martin, MD, MSc

Disclosures

January 10, 2018

An Observational Study of the Efficacy of Cisatracurium Compared to Vecuronium in Patients With or at Risk for ARDS

Sottile PD, Kiser TH, Burnham EL, et al
Am J Respir Crit Care Med. 2017 Dec 14. [Epub ahead of print]

Study Summary

A prominently published study reported an improvement in mortality in acute respiratory distress syndrome (ARDS) patients who received early treatment with the paralyzing agent cisatracurium.[1] Cisatracurium, however, has not been adopted for routine clinical use in ARDS patients amidst a lack of additional studies replicating the original findings.

The authors conducted this study to determine if cisatracurium is associated with benefits when compared with other common pharmacologic paralyzing agents. They queried a nationally representative administrative dataset using ICD codes to identify mechanically ventilated patients, use of the paralytic agents cisatracurium or vecuronium for at least 2 days, and the respective clinical outcomes. They used propensity matching to balance patient and hospital factors that differed between the two groups. The results showed no difference in mortality (odds ratio [OR], 0.932; P=.40) or hospital days (-0.66 days; P=.411) between groups, although cisatracurium-treated patients had fewer ventilator days (-1.01 days, P=.005) and ICU days (-0.98 days, P=.028). Both groups were equally likely to be discharged home (OR, 1.19; P=.056). The authors concluded that cisatracurium use in ARDS was associated with improvements in some clinically important outcomes but not mortality, suggesting that cisatracurium may be the preferred neuromuscular blocking agent for patients at risk for and with ARDS.

Viewpoint

While the conclusion of this study may be correct—that cisatracurium use in mechanically ventilated patients is associated with a shorter time on the ventilator without improvements in mortality—there are several caveats to this study. First and foremost, the study is observational, meaning that there was no control over which patients were treated and how they were treated (dose, duration and monitoring of paralysis, and the host of other supportive measures that go along with severe hypoxemic respiratory failure); and thus the conclusions show a simple association between cisatracurium use and time on the ventilator when compared with vecuronium. However, the original study suggesting benefit to paralytic use compared cisatracurium versus placebo,[1] whereas this study compared two active paralytic agents. Is it possible that cisatracurium (a short-acting agent) use results in a shorter duration of mechanical ventilation compared with vecuronium (a longer-acting agent)? It's a fair assumption that it could simply be based on the duration of drug effect, with vecuronium resulting in more prolonged paralysis. This study also relied on limited administrative coding methods to identify patients with important conditions, such as ARDS, and attempted to use complex statistical methodologies such as propensity matching methods to avoid confounding due to treatment bias and other differences between groups. Despite these limitations, the study results are plausible but should not change clinical practice pending the results of a large confirmatory trial currently underway in North America.[2]

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