Partial Neuromuscular Blockade during Partial Ventilatory Support in Sedated Patients with High Tidal Volumes.

Autor: Doorduin J; 1 Department of Critical Care Medicine and., Nollet JL; 1 Department of Critical Care Medicine and., Roesthuis LH; 1 Department of Critical Care Medicine and., van Hees HW; 2 Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands., Brochard LJ; 3 Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; and.; 4 Keenan Research Centre for Biomedical Science, Toronto, Ontario, Canada., Sinderby CA; 3 Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; and.; 4 Keenan Research Centre for Biomedical Science, Toronto, Ontario, Canada., van der Hoeven JG; 1 Department of Critical Care Medicine and., Heunks LM; 1 Department of Critical Care Medicine and.
Jazyk: angličtina
Zdroj: American journal of respiratory and critical care medicine [Am J Respir Crit Care Med] 2017 Apr 15; Vol. 195 (8), pp. 1033-1042.
DOI: 10.1164/rccm.201605-1016OC
Abstrakt: Rationale: Controlled mechanical ventilation is used to deliver lung-protective ventilation in patients with acute respiratory distress syndrome. Despite recognized benefits, such as preserved diaphragm activity, partial support ventilation modes may be incompatible with lung-protective ventilation due to high Vt and high transpulmonary pressure. As an alternative to high-dose sedatives and controlled mechanical ventilation, pharmacologically induced neuromechanical uncoupling of the diaphragm should facilitate lung-protective ventilation under partial support modes.
Objectives: To investigate whether partial neuromuscular blockade can facilitate lung-protective ventilation while maintaining diaphragm activity under partial ventilatory support.
Methods: In a proof-of-concept study, we enrolled 10 patients with lung injury and a Vt greater than 8 ml/kg under pressure support ventilation (PSV) and under sedation. After baseline measurements, rocuronium administration was titrated to a target Vt of 6 ml/kg during neurally adjusted ventilatory assist (NAVA). Thereafter, patients were ventilated in PSV and NAVA under continuous rocuronium infusion for 2 hours. Respiratory parameters, hemodynamic parameters, and blood gas values were measured.
Measurements and Main Results: Rocuronium titration resulted in significant declines of Vt (mean ± SEM, 9.3 ± 0.6 to 5.6 ± 0.2 ml/kg; P < 0.0001), transpulmonary pressure (26.7 ± 2.5 to 10.7 ± 1.2 cm H 2 O; P < 0.0001), and diaphragm electrical activity (17.4 ± 2.3 to 4.5 ± 0.7 μV; P < 0.0001), and could be maintained under continuous rocuronium infusion. During titration, pH decreased (7.42 ± 0.02 to 7.35 ± 0.02; P < 0.0001), and mean arterial blood pressure increased (84 ± 6 to 99 ± 6 mm Hg; P = 0.0004), as did heart rate (83 ± 7 to 93 ± 8 beats/min; P = 0.0004).
Conclusions: Partial neuromuscular blockade facilitates lung-protective ventilation during partial ventilatory support, while maintaining diaphragm activity, in sedated patients with lung injury.
Databáze: MEDLINE
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