Brunini Michael, Forel Jean-Marie, Muracciole Xavier, Roch Antoine, Barbolosi Dominique, Papazian Laurent
Università di Corsica Pasquale Paoli, Corte, Corsica, France.
Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, Marseille, France.
Intensive Care Med. 2025 Aug 6. doi: 10.1007/s00134-025-08064-z.
The beneficial effects of systematic cisatracurium administration observed in the ACURASYS randomized, multicenter, double-blinded trial may depend on patient-specific factors. This post hoc analysis aimed to explore whether the impact of cisatracurium on mortality varies with baseline characteristics.
A Markov chain analysis was conducted using daily clinical states from inclusion to day 90: death (state 0), under mechanical ventilation (state 1), or weaned and alive at day 90 (state 2). Patient trajectories were modeled accordingly.
Among the 321 included patients, subgroup analysis following univariate analysis focused on 130 individuals under 60 years with non-fatal McCabe scores. Within this subgroup, cisatracurium administration and absence of vasopressor use significantly reduced the probability of remaining ventilated. Estimated survival increased therefore from 0.63 (placebo group, N = 62) to 0.93 (cisatracurium group, N = 68). In contrast, among patients with a rapidly or ultimately fatal prognosis according to McCabe score, the probability of survival did not differ substantially between the placebo and cisatracurium groups. Among patients with a PaO:FiO ratio ≤ 100 mmHg at inclusion (N = 65), the estimated survival rate at day 90 was 0.93 in the cisatracurium arm compared with 0.63 in the placebo arm. For patients with a PaO:FiO ratio > 100 mmHg at inclusion (N = 98), the corresponding survival rates were 0.92 and 0.63, respectively. In patients aged ≥ 60 years (N = 158), the daily probability of remaining mechanically ventilated was not influenced by any covariate, including the administration of cisatracurium. These results were confirmed by the performed simulations.
The systematic and short-term administration of cisatracurium in patients with moderate-to-severe ARDS appears to confer greater survival benefit in those with a higher baseline life expectancy. Further validation through retrospective and prospective studies is warranted.
在ACURASYS随机、多中心、双盲试验中观察到的系统性给予顺式阿曲库铵的有益效果可能取决于患者的个体因素。这项事后分析旨在探讨顺式阿曲库铵对死亡率的影响是否随基线特征而变化。
使用从纳入研究至第90天的每日临床状态进行马尔可夫链分析：死亡（状态0）、接受机械通气（状态1）或在第90天脱机且存活（状态2）。据此对患者轨迹进行建模。
在纳入的321例患者中，单变量分析后的亚组分析聚焦于130例年龄在60岁以下且麦凯布评分非致命的个体。在该亚组中，给予顺式阿曲库铵且未使用血管升压药显著降低了持续通气的概率。因此，估计生存率从0.63（安慰剂组，N = 62）提高到0.93（顺式阿曲库铵组，N = 68）。相比之下，根据麦凯布评分预后迅速或最终致命患者中，安慰剂组和顺式阿曲库铵组的生存率无显著差异。纳入时动脉血氧分压与吸入氧浓度比值（PaO:FiO）≤100 mmHg的患者（N = 65）中，顺式阿曲库铵组第90天的估计生存率为0.93，而安慰剂组为0.63。纳入时PaO:FiO > 100 mmHg的患者（N = 98）中，相应的生存率分别为0.92和0.63。在年龄≥60岁的患者（N = 158）中，包括给予顺式阿曲库铵在内的任何协变量均未影响每日持续机械通气的概率。所进行的模拟证实了这些结果。
在中重度急性呼吸窘迫综合征患者中系统性短期给予顺式阿曲库铵似乎对基线预期寿命较高的患者有更大的生存益处。有必要通过回顾性和前瞻性研究进行进一步验证。
