Continuous Infusion Versus Intermittent Boluses of Cisatracurium in the Early Management of Pediatric Acute Respiratory Distress Syndrome: A Multicenter, Randomized Controlled Trial.

Summary

In this multicenter pediatric RCT, 24-hour continuous cisatracurium infusion improved oxygenation, increased extubation rates and shortened PICU stay compared with intermittent boluses; benefits were confined to moderate-to-severe PARDS and were not seen in mild cases.

Key Findings

• Continuous cisatracurium infusion for 24 h increased extubation rate compared with intermittent boluses after accounting for death as a competing event.
• Benefits were concentrated in moderate-to-severe PARDS (SHR for extubation 3.25, 95% CI 1.69–6.25, p<0.001) and not seen in mild PARDS.
• By day 7, moderate-to-severe PARDS patients receiving infusion had lower FiO2, mean airway pressure, and oxygenation index, and earlier PICU discharge (SHR 3.16, 95% CI 1.64–6.11).

Clinical Implications

For moderate-to-severe PARDS, consider a 24-hour continuous cisatracurium infusion when neuromuscular blockade is indicated to improve oxygenation and facilitate earlier ventilator liberation; benefits appear minimal in mild PARDS. Monitor sedation, neuromuscular recovery, and ICU-acquired weakness risks.

Limitations

• Sample size not specified in provided abstract (external validation of results and power unclear)
• Short (24 h) NMBA exposure window—longer-term neuromuscular outcomes and adverse events not detailed in abstract

Future Directions

Confirm findings in larger, fully powered pediatric trials with detailed neuromuscular and functional outcomes, evaluate optimal infusion duration, and assess safety (ICU-acquired weakness) over longer follow-up.