Reevaluation Of Systemic Early Neuromuscular Blockade (ROSE)
Acute Respiratory Distress Syndrome
About this trial
This is an interventional treatment trial for Acute Respiratory Distress Syndrome focused on measuring ARDS, neuromuscular blocker, cisatracurium
Eligibility Criteria
Inclusion Criteria
- Age > 18 years
Presence of all of the following conditions for < 48 hours:
i. PaO2/FiO2 < 150 with PEEP >/= 8 cm H2O OR, if ABG not available, SaO2/FiO2 ratio that is equivalent to a PaO2/FiO2 < 150 with PEEP >/= 8 cm H2O , and a confirmatory SaO2/FiO2 ratio that is again equivalent 1-6 hours later
ii. Bilateral opacities not fully explained by effusions, lobar/lung collapse, or nodules.
iii. Respiratory failure not fully explained by cardiac failure or fluid overload; need objective assessment (e.g., echocardiography) to exclude hydrostatic edema if no risk factor present.
Patients must be enrolled within 48 hours of meeting inclusion criteria.
Exclusion Criteria:
- Lack of informed consent
- Continuous neuromuscular blockade at enrollment
- Known pregnancy
- Currently receiving ECMO therapy
- Chronic respiratory failure defined as PaCO2 > 60 mm Hg in the outpatient setting
- Home mechanical ventilation (non-invasive ventilation or via tracheotomy) except for CPAP/BIPAP used solely for sleep-disordered breathing
- Actual body weight exceeding 1 kg per centimeter of height
- Severe chronic liver disease defined as a Child-Pugh score of 12-15 (Appendix A2)
- Bone marrow transplantation within the last 1 year
- Expected duration of mechanical ventilation of < 48 hours
- Decision to withhold life-sustaining treatment; except in those patients committed to full support except cardiopulmonary resuscitation if an actual cardiac arrest occurs
- Moribund patient not expected to survive 24 hours; if CPR provided, assess for moribund status greater than 6 from CPR conclusion
- Diffuse alveolar hemorrhage from vasculitis
- Burns > 70% total body surface
- Unwillingness to utilize the ARDS Network 6 ml/kg IBW ventilation protocol
- Previous hypersensitivity or anaphylactic reaction to cisatracurium
- Neuromuscular conditions that may potentiate neuromuscular blockade and/or impair spontaneous ventilation (Appendix A2)
- Neurologic conditions undergoing treatment for intracranial hypertension
- Enrollment in an interventional ARDS trial with direct impact on neuromuscular blockade and PEEP
- >120 hours of mechanical ventilation
- P/F < 200 mmHg at the time of randomization (if available)
Sites / Locations
- UCSF Fresno
- Ronald Reagan UCLA Medical Center
- UC Davis Medical Center
- UCSF Medical Center
- Stanford University Hospital
- Medical Center of Aurora
- University of Colorado Hospital
- Denver Health Medical Center
- Swedish Medical Center
- Indiana University Methodist Hospital
- University Medical Center
- Maine Medical Center
- Tufts Medical Center
- Massachusetts General Hospital
- Brigham and Women's Hospital
- Beth Israel Deaconess Medical Center
- Baystate Medical Center
- St. Vincent's Hospital
- University of Michigan Medical Center
- Henry Ford Medical Center
- University of Mississippi Medical Center
- Montefiore Medical Center
- Mt. Sinai Hospital
- Wesley Long Hospital
- Wake Forest Baptist Medical Center
- Summa Akron City Hospital
- University of Cincinnati Medical Center
- Cleveland Clinic Foundation
- Ohio State University Wexner Medical Center
- Oregon Health and Science University
- Penn State Hershey Medical Center
- UPMC Presbyterian/Mercy/Shadyside
- Vanderbilt University Medical Center
- Intermountain Medical Center
- McKay-Dee Hospital
- Utah Valley Regional Medical Center
- University Hospital
- LDS Hospital
- University or Virginia Health System
- VCU Medical Center
- Harborview Medical Center
- University of Washington Medical Center
- Swedish Hospital Cherry Hill
- Swedish Hospital First Hill
Arms of the Study
Arm 1
Arm 2
Active Comparator
No Intervention
Early Neuromuscular Blockade (NMB)
Control: No Routine Early NMB
Patients will receive cisatracurium besylate for the first 48 hours of the trial.
Use of non-study NMB will be discouraged.