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evident
Original paper
2010NEJMPulmonary/Critical Care

ACURASYS

Neuromuscular blockers in early acute respiratory distress syndrome

RCTARDS

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Overview

Early cisatracurium improved adjusted survival in severe early ARDS in ACURASYS.

Clinical takeaway

ACURASYS made early paralysis a serious option in severe ARDS, but its place changed after ROSE tested a modern high-PEEP/light-sedation strategy.

Key result

Adjusted 90-day mortality favored cisatracurium (HR 0.68; 95% CI 0.48-0.98; P=0.04); crude 90-day mortality 31.6% vs 40.7% (P=0.08).

Practice impact

Consider short-course paralysis selectively for severe ventilator dyssynchrony or refractory hypoxemia, not routine ARDS care.

Evidence

Study design

Randomized, double-blind, placebo-controlled trial.

Enrollment

340

Follow-up

90 days.

Geography

France

Clinical question

Does early neuromuscular blockade improve outcomes in severe early ARDS?

Population

  • Mechanically ventilated adults with severe ARDS (PaO2:FIO2 <150 on PEEP >=5 cm H2O) of onset within the previous 48 hours.

Intervention

Cisatracurium infusion for 48 hours.

Comparator

Placebo infusion with deep sedation.

Primary outcome

90-day in-hospital mortality adjusted for baseline severity.

Early cisatracurium was associated with lower adjusted 90-day mortality in severe early ARDS.

Hazard ratio / 0.68 / 95% CI 0.48-0.98 / p=0.04

Key results

  • Adjusted 90-day mortality favored cisatracurium: HR 0.68 (95% CI 0.48-0.98; P=0.04).
  • Crude 90-day mortality was 31.6% with cisatracurium vs 40.7% with placebo (P=0.08, not significant).
  • 28-day mortality was 23.7% vs 33.3% (P=0.05).
  • Barotrauma was reduced.
  • ICU-acquired paresis was not significantly increased in trial follow-up.

Harms

  • Deep sedation and paralysis can mask seizures, pain, awareness, and neurologic change.
  • ICU-acquired weakness remains a practical concern.

Clinical Use

Practice impact

  • Prompted increased use of early neuromuscular blockade in severe ARDS before ROSE tempered routine use.

Applicability

  • Severe early ARDS with ventilator dyssynchrony or refractory hypoxemia despite lung-protective ventilation.

Limitations

  • Small single-country trial with deep sedation in both arms.
  • Modern sedation and PEEP approaches differ.

Common misinterpretations

  • Do not paralyze all ARDS patients automatically; ACURASYS is best interpreted alongside ROSE.

Related evidence

ARDSNet ARMA - ContextROSE - Contrasting Result

Citation

Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107-1116. doi:10.1056/NEJMoa1005372

The hazard ratio for death at 90 days in the cisatracurium group, as compared with the placebo group, was 0.68 (95% confidence interval [CI], 0.48 to 0.98; P=0.04), after adjustment for both the baseline PaO2:FIO2 and plateau pressure and the Simplified Acute Physiology II score.