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The following is a summary of “Impact of aggressive and conservative propensity for initiation of neuromuscular blockade in mechanically ventilated patients with hypoxemic respiratory failure,” published in the August 2024 issue of Critical Care by Shahn et al. 

Researchers conducted a retrospective study to assess the effect of neuromuscular blockade (NMB) initiation aggressiveness using incremental interventions in patients who were on ventilation.   

They examined patients on ventilation with PaO2/FiO2 ratio < 50 mmHg and PEEP ≥8cmH2O from the Medical Information Mart of Intensive Care IV database (MIMIC-IV version 1.0). They evaluated the impact of incremental interventions on in-hospital mortality and ventilator-free days by modifying hourly propensity for NMB initiation to be aggressive or conservative relative to usual care, adjusted for confounding with inverse probability weighting.    

The results showed that of 5,221 patients,13.3% initiated NMB. Incremental interventions showed a substantial effect on NMB usage: a 5-fold higher hourly odds of initiation increased usage to 36.5% (CI = [34.3%,38.7%]), while 5-fold lower odds reduced usage to 3.8% (CI = [3.3%,4.3%]). Both aggressive and conservative strategies showed a U-shaped mortality relationship. A 5-fold higher or lower propensity increased in-hospital mortality by 2.6% (0.95 CI = [1.5%,3.7%]) or 1.3% (0.95 CI= [0.1%,2.5%]), respectively. In a secondary analysis of a healthier patient cohort, results were similar, with conservative strategies improving ventilator-free days.   

Investigators concluded that aggressive or conservative initiation of NMB may increase mortality, leading to increased ventilator-free days with minimal impact.   

Source: sciencedirect.com/science/article/abs/pii/S0883944124002909