Treatment with neuromuscular blocking agents and the risk of in-hospital mortality among mechanically ventilated patients with severe sepsis. (Petrillo)

Steingrub JS, Lagu T, Rothberg MB, Nathanson BH, Raghunathan K, Lindenauer PK. Treatment With Neuromuscular Blocking Agents and the Risk of In-Hospital Mortality Among Mechanically Ventilated Patients With Severe Sepsis. Crit Care Med. 2013 Aug 26. [Epub ahead of print]

OBJECTIVES: Recent trials suggest that treatment with neuromuscular blocking agents may improve survival in patients requiring mechanical ventilation for acute respiratory distress syndrome. We examined the association between receipt of a neuromuscular blocking agent and in-hospital mortality among mechanically ventilated patients with severe sepsis.

DESIGN: A pharmacoepidemiologic cohort study of patients with sepsis and a respiratory infection who had been admitted to intensive care and placed on mechanical ventilation within the first 2 days of hospitalization. We used propensity score matching and instrumental variable methods to compare the outcomes of patients treated with neuromuscular blocking agents within the first 2 hospital days to those who were not. Sensitivity analysis was used to model the effects of a hypothetical unmeasured confounder.

SETTING: Three hundred thirty-nine U.S. hospitals that participated in the Premier Perspective database between 2004 and 2006.

PATIENTS: Seven thousand eight hundred sixty-four patients met inclusion criteria, including 1,818 (23%) who were treated with a neuromuscular blocking agent by hospital day 2.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Patients who received neuromuscular blocking agents were younger (mean age, 62 vs 68), more likely to be treated with vasopressors (69% vs 65%)and had a lower in-hospital mortality rate (31.9% vs 38.3%, p < 0.001). In 3,518 patients matched on the propensity for treatment, receipt of a neuromuscular blocking agent was associated with a reduced risk of in-hospital mortality (risk ratio, 0.88; 95% CI, 0.80, 0.96). An analysis using the hospital neuromuscular blocking agent-prescribing rate as an instrumental variable found receipt of a neuromuscular blocking agent associated with a 4.3% (95% CI, -11.5%, 1.5%) reduction in in-hospital mortality.

CONCLUSIONS: Among mechanically ventilated patients with severe sepsis and respiratory infection, early treatment with a neuromuscular blocking agent is associated with lower in-hospital mortality.

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