Mathias Stöckl1, Christoph Testori2, Fritz Sterz2, Michael Holzer2, Christoph Weiser2, Andreas Schober2, Graham Nichol3, Martin Frossard2, Harald Herkner2, Jasmin Kechvar4, Heidrun Losert5. 1. Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine I, Brothers of Saint John of God Hospital, Eisenstadt, Austria. 2. Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria. 3. Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA, USA. 4. Department of Neurology, Medical University of Vienna, Vienna, Austria. 5. Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria. Electronic address: heidrun.losert@meduniwien.ac.at.
Abstract
AIM OF THE STUDY: Current guidelines recommend targeted temperature management to improve neurological outcome after cardiac arrest. Evidence regarding an ideal sedative/analgesic regimen including skeletal muscle paralysis is limited. METHODS: Patients were randomized to either a continuous administration of rocuronium (continuous-NMB-group) or to a continuous administration of saline supplemented by rocuronium bolus administration if demanded (bolus-NMB-group). The primary outcome was the number of shivering episodes. Secondary outcomes included survival and neurological status one year after cardiac arrest, time to awakening, length of stay as well as required cumulative dose of rocuronium, midazolam and fentanyl. RESULTS:Sixty-three patients (32 continuous-NMB-group; 31 bolus-NMB-group) were enrolled. Differences in baseline characteristics were not significant. Shivering episodes were detected in 94% of the patients in the bolus-NMB-group compared to 25% of the patients receiving continuous rocuronium infusion (p<0.01). The continuous-NMB-group received significant lower doses of midazolam (4.3±0.8mg/kg vs. 5.1±0.9mg/kg, p<0.01) and fentanyl (62±14μg/kg vs. 71±7μg/kg, p<0.01), but higher cumulative doses of rocuronium (7.8±1.8mg/kg vs. 2.3±1.6mg/kg, p<0.01). Earlier awakening (2 [IQR 2;3] vs. 4 [IQR 2;7.5] days, p=0.04) and decreased length of stay at the ICU (6 [IQR 3;5.9] vs. 10 [IQR 5;15] days, p=0.03) were observed in the continuous-NMB-group. There were no significant differences in survival and quality of life 12 months after cardiac arrest. CONCLUSIONS: Continuous neuromuscular blockade during the first day after resuscitation reduced shivering, midazolam and fentanyl requirement, time to awakening and discharge from intensive care unit. There were no differences in overall survival, cooling rate and time to target temperature.
RCT Entities:
AIM OF THE STUDY: Current guidelines recommend targeted temperature management to improve neurological outcome after cardiac arrest. Evidence regarding an ideal sedative/analgesic regimen including skeletal muscle paralysis is limited. METHODS:Patients were randomized to either a continuous administration of rocuronium (continuous-NMB-group) or to a continuous administration of saline supplemented by rocuronium bolus administration if demanded (bolus-NMB-group). The primary outcome was the number of shivering episodes. Secondary outcomes included survival and neurological status one year after cardiac arrest, time to awakening, length of stay as well as required cumulative dose of rocuronium, midazolam and fentanyl. RESULTS: Sixty-three patients (32 continuous-NMB-group; 31 bolus-NMB-group) were enrolled. Differences in baseline characteristics were not significant. Shivering episodes were detected in 94% of the patients in the bolus-NMB-group compared to 25% of the patients receiving continuous rocuronium infusion (p<0.01). The continuous-NMB-group received significant lower doses of midazolam (4.3±0.8mg/kg vs. 5.1±0.9mg/kg, p<0.01) and fentanyl (62±14μg/kg vs. 71±7μg/kg, p<0.01), but higher cumulative doses of rocuronium (7.8±1.8mg/kg vs. 2.3±1.6mg/kg, p<0.01). Earlier awakening (2 [IQR 2;3] vs. 4 [IQR 2;7.5] days, p=0.04) and decreased length of stay at the ICU (6 [IQR 3;5.9] vs. 10 [IQR 5;15] days, p=0.03) were observed in the continuous-NMB-group. There were no significant differences in survival and quality of life 12 months after cardiac arrest. CONCLUSIONS: Continuous neuromuscular blockade during the first day after resuscitation reduced shivering, midazolam and fentanyl requirement, time to awakening and discharge from intensive care unit. There were no differences in overall survival, cooling rate and time to target temperature.
Authors: Teresa L May; Richard R Riker; Gilles L Fraser; Karen G Hirsch; Sachin Agarwal; Christine Duarte; Hans Friberg; Eldar Søreide; John McPherson; Robert Hand; David Kent; Niklas Nielsen; David B Seder Journal: Crit Care Med Date: 2018-10 Impact factor: 7.598
Authors: Byung Kook Lee; In Soo Cho; Joo Suk Oh; Wook Jin Choi; Jung Hee Wee; Chang Sun Kim; Won Young Kim; Chun Song Youn Journal: PLoS One Date: 2018-12-17 Impact factor: 3.240
Authors: Ari Moskowitz; Lars W Andersen; Jon C Rittenberger; Robert Swor; Raghu R Seethala; Michael C Kurz; Katherine M Berg; Maureen Chase; Michael N Cocchi; Anne V Grossestreuer; Xiaowen Liu; Mathias J Holmberg; Clifton W Callaway; Michael W Donnino Journal: J Am Heart Assoc Date: 2020-08-27 Impact factor: 6.106