Medical News Stories
Continuous Versus Intermittent Neuromuscular Blockade in Patients During Targeted Temperature Management After Resuscitation from Cardiac Arrest – a Randomized, Double Blinded, Double Dummy, Clinical Trial
Stockl M, Testori C, Sterz F, et al. Resuscitation. 2017; 120: 14-19.
Study Question: Does continuous neuromuscular blockade (CNMB) decrease the number of shivering episodes compared to bolus doses (BNMB) during targeted temperature management (TTM) after resuscitation from out-of-hospital cardiac arrest (OHCA)?
Study Description: This randomized study was conducted in adults who survived cardiopulmonary OHCA, arrived to the emergency department within six hours of resuscitation, and were eligible to receive TTM. Patients were randomized to receive a continuous infusion of rocuronium 0.25 mg/kg/hr with boluses of saline if shivering was noticed or a continuous infusion of saline with boluses of rocuronium 0.25 mg/kg for shivering. Both groups were started on midazolam 0.125 mg/kg/hr and fentanyl 2 mcg/kg/hr infusions that were increased incrementally for each episode of shivering. The primary endpoint was the number of shivering episodes during TTM.
Results: A total of 63 patients were enrolled in the study (32 in the CNMB group, 31 in the BNMB group). Shivering episodes occurred more frequently in the BNMB group than the CNMB group (94% vs. 25% respectively; p < 0.01). The CNMB group received higher doses of rocuronium (7.8 ± 1.8 mg/kg vs. 2.3 ± 1.6 mg/kg; p < 0.01) but lower doses of midazolam (4.3 ± 0.8 mg/kg vs. 5.1 ± 0.9 mg/kg; p < 0.01) and fentanyl (0.062 ± 0.014 mg/kg vs. 0.071 ± 0.007 mg/kg, p <0.01). Patients in the CNMB group had a shorter ICU length of stay (LOS) (6 days vs. 10 days; p = 0.03) and sooner awakening (2 days vs. 4 days; p = 0.04) than patients in the BNMB group. There was no significant difference in overall mortality or neurologic outcome.
Conclusion: CNMB reduced episodes of shivering, midazolam and fentanyl requirements, time to awakening and ICU LOS.
Perspective: NMB has no overall benefit for OHCA patients. This study showed no difference in mortality and NMB are associated with several adverse events including critical illness polyneuropathy. Continuous EEG-monitoring was not used to assess the patient’s level of sedation or seizure activity. These patients were predominantly witnessed cardiac arrest with shockable rhythms that were given set doses of analgesia and sedation, which likely cannot be extrapolated to other post arrest populations.