Two paths to paralysis: A multicenter comparison of cisatracurium to atracurium in the management of acute respiratory distress syndrome.

PURPOSE

Neuromuscular blocking agents (NMBAs) such as cisatracurium and atracurium are used to facilitate lung-protective ventilation in moderate-to-severe acute respiratory distress syndrome (ARDS). Although cisatracurium has been more extensively studied, data comparing these agents directly are limited. This study compares clinical outcomes between atracurium and cisatracurium in patients with moderate-to-severe ARDS.

MATERIALS AND METHODS

This multicenter, retrospective cohort study was conducted between January 2017 and December 2023 across 11 Ascension Health hospitals. Mechanically ventilated adults with a PaO/FiO ratio < 150 who received a continuous infusion of atracurium or cisatracurium for at least 12 h within 48 h of ARDS diagnosis were included. The primary endpoint was ventilator-free days at day 28.

RESULTS

A total of 384 patients were included, with 192 in each group. Median 28-day ventilator-free days did not differ between groups in the unmatched (0 [IQR 0-16.7] vs. 0 [IQR 0-16.4], p = 0.72) or matched (0 [IQR 0-18.3] vs. 0 [IQR 0-14.4], p = 0.09) cohorts. These findings were further confirmed by multivariable analysis. After matching, there were no significant differences in 90-day inpatient mortality, length of stay, or duration of mechanical ventilation. While patients receiving cisatracurium showed greater improvements in PaO/FiO ratio at 72 h (p < 0.01), resolution of ARDS was similar between groups. Safety outcomes were comparable between agents.

CONCLUSIONS

Atracurium and cisatracurium demonstrated similar safety and effectiveness in patients with moderate-to-severe ARDS. These results suggest that atracurium is a viable alternative to cisatracurium for the treatment of ARDS.