Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome (ACURASYS)

Neuromuscular blocking agents (NMBAs) were hypothesized to improve outcomes in severe ARDS by eliminating patient-ventilator dyssynchrony and reducing oxygen consumption. ACURASYS was the first large RCT.

Multicenter RCT (20 French ICUs, n=340) comparing cisatracurium infusion for 48 hours vs. placebo in patients with severe ARDS (P/F <150).

Cisatracurium improved 90-day mortality (31.6% vs 40.7%, HR 0.68, p=0.04) and increased ventilator-free days. No difference in ICU-acquired weakness.

ACURASYS showed benefit, but the larger ROSE trial (2019) showed no benefit with lighter sedation as control. Current guidelines do NOT routinely recommend NMBAs in ARDS — use only for specific indications (severe dyssynchrony, refractory hypoxemia).

Control arm used deep sedation — the benefit may reflect harm from deep sedation rather than benefit from NMBAs. ROSE trial refuted these findings.