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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