ARDS: ROSE Reevaluation of Systemic Early Neuromuscular Blockade

Question 1

ROSE Clinical Q

Answer 1

In patients with moderate to severe ARDS, does the early use of continuous neuromuscular blockade with cisatracurium improve mortality when used with current light sedation protocols?

Question 2

ROSE Bottom Line

Answer 2

Not only does early neuromuscular blockade not reduce mortality when using modern light sedation protocols, it was associated with an increase in ICU-acquired weakness and serious adverse cardiovascular events. Contradicts ACURASYS

Question 3

ROSE Primary Outcome

Answer 3

90-day in-hospital death from any cause

Question 4

What study does ROSE contradict

Answer 4

ACURASYS

Question 5

Rose Intervention Groups

Answer 5

Randomized to a group:

• Early NM blockade - Treated with 48-hrs continuous cisatracurium with deep sedation
• Usual care - Routine NM blockade with light sedation
• Cisatracurium: 15mg bolus of cisatracurium once, and then a continuous infusion of 37.5mg/hr deeply sedated (RASS -5) within 4hrs of randomization
• Usual care: lightly sedated (RASS 0 to -1)
• All patients were ventilated using low-tidal volume ventilation with a high PEEP strategy unless medically contraindicated

Question 6

ROSE Criticisms

Answer 6

1. A large portion of patients were excluded due to prior to exposure to NM blockade
2. Prone position was by the discretion of the treating physician
3. This trial was unblinded but given the intervention blinding would have been impossible
4. Cross-over exposure may have led to confounding the results
   
   1. 14% of cisatracurium patients stopped early
   2. 17% of control arm received cisatracurium