Sedation Practices during Continuous Neuromuscular Blockade for Acute Respiratory Distress Syndrome

Rationale: Neuromuscular blockade (NMB) is frequently used during acute respiratory distress syndrome (ARDS) to improve ventilator synchrony. Which sedating medications are used concomitantly during NMB and whether sedation choice influences patient outcomes are unclear. Objectives: To determine national sedation practice patterns during NMB in patients with and at risk for ARDS and to establish whether the use of propofol and opioids compared with benzodiazepines and opioids is associated with improved outcomes. Methods: Using a U.S. national database from 2010 to 2021, intubated and mechanically ventilated patients receiving NMB for a diagnosis of ARDS or an ARDS risk factor over at least two hospital days after admission were included. Charges for sedation and analgesia during the first two hospital days were recorded for each patient. The relationships between propofol and opioids and between benzodiazepines and opioids, with a primary outcome of ventilator-free days, as well as secondary outcomes of 28-day survival and discharge home were examined in multivariable analyses. Results: We determined that the use of propofol has increased compared with that of benzodiazepines as the primary sedative used during NMB for ARDS. Compared with benzodiazepine and opioid use, propofol and opioid use during NMB for ARDS was associated with increased ventilator-free days (adjusted odds ratio, 1.38 [95% confidence interval, 1.24-1.54]), greater odds for survival at 28 days (adjusted odds ratio, 1.15 [95% confidence interval, 1.01-1.31]), and greater odds for discharge home (adjusted odds ratio, 1.26 [95% confidence interval, 1.09-1.46]), adjusting for patient-level and hospital-level characteristics. Conclusions: From 2010 to 2021, sedation practice during NMB for ARDS shifted from predominately benzodiazepine use to predominately propofol use. The use of propofol and opioids is associated with an increase in ventilator-free days compared with the use of benzodiazepines and opioids. These results suggest that sedation choice during NMB for ARDS may affect clinical outcomes; further investigation is needed to validate these findings.