Society of Critical Care Medicine Guidelines for the Administration of Neuromuscular Blockade in Adults With Acute Respiratory Distress Syndrome.

Summary

A GRADE-based SCCM guideline issues two conditional recommendations on NMBA use in adult ARDS: recommend use when PaO2/FiO2 <150, and acknowledge equipoise for titration strategy, sedation/analgesia monitoring, and proned patients due to limited evidence. The process followed strict conflict-of-interest policies and systematic reviews for PICO questions.

Key Findings

• SCCM panel issued two conditional recommendations on NMBA use in adult ARDS.
• Recommend NMBAs when PaO2/FiO2 is <150.
• Equipoise for titratable vs fixed-dose dosing, monitoring-based sedation/analgesia strategies, and NMBA use during prone positioning due to limited evidence.

Clinical Implications

For adult ARDS with PaO2/FiO2 <150, consider initiating an NMBA. Be cautious with dosing strategy, sedation/analgesia depth monitoring, and use during prone positioning given evidence uncertainty and patient safety considerations.

Limitations

• Predominantly conditional recommendations reflect limited high-certainty evidence
• Important gaps remain for dosing strategies, sedation monitoring, and proned patients

Future Directions

High-quality RCTs comparing titratable vs fixed-dose NMBA strategies, optimal sedation/analgesia monitoring, and evaluating NMBA use during prone positioning.