{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T14:38:57Z","timestamp":1788014337458,"version":"build-2784847793"},"reference-count":16,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,1,6]],"date-time":"2026-01-06T00:00:00Z","timestamp":1767657600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Association M\u00e9dicale Universitaire Montfort (AMUM), Department of Medicine","award":["2025-A15"],"award-info":[{"award-number":["2025-A15"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diseases"],"abstract":"<jats:p>Background: Neuromuscular blockade (NMB) is frequently used in moderate-to-severe acute respiratory distress syndrome (ARDS) to optimize ventilatory synchrony and minimize ventilator-induced lung injury. However, comparative real-world data on different NMB strategies remain limited. Objective: To describe patterns of neuromuscular blockade use in ARDS and describe clinical outcomes across four NMB strategies: intermittent rocuronium, continuous cisatracurium, escalation from rocuronium to cisatracurium, and de-escalation from cisatracurium to rocuronium. Methods: A retrospective chart review was conducted in an 18-bed tertiary ICU at H\u00f4pital Montfort (Ottawa, Canada) between November 2021 and March 2025. Adult ARDS patients who received NMB for &gt;24 h were included. Continuous variables (age, ventilation time, ICU stay) were summarized as means \u00b1 SD and median [IQR]; categorical variables (sex, ARDS etiology, mortality) as counts and percentages. Inferential testing was limited to baseline characteristics; clinical outcomes were summarized descriptively. Results: Fifty-one patients met inclusion criteria: rocuronium (n = 20), cisatracurium (n = 14), rocuronium\u2192cisatracurium (n = 8), and cisatracurium\u2192rocuronium (n = 9). Mean ventilation durations were 280, 195, 272, and 262 h, respectively; corresponding ICU stays were 245, 237, 380, and 299 h. Mortality ranged from 25% to 56%. Escalation from rocuronium to cisatracurium typically reflected persistent dyssynchrony or worsening oxygenation, whereas de-escalation occurred in improving patients with residual ventilatory drive. Variability in corticosteroid use, adjunctive proning, and epoprostenol were potential confounders. Conclusions: Distinct NMB use patterns in ARDS reflect bedside clinical judgment rather than predefined thresholds. Patient trajectory and dyssynchrony severity appear to drive NMBA escalation decisions more than oxygenation indices alone. These findings highlight the need for prospective studies defining standardized criteria for NMB initiation, escalation, and weaning in ARDS.<\/jats:p>","DOI":"10.3390\/diseases14010022","type":"journal-article","created":{"date-parts":[[2026,1,6]],"date-time":"2026-01-06T11:13:18Z","timestamp":1767697998000},"page":"22","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Clinical Patterns of Rocuronium and Cisatracurium Use in Acute Respiratory Distress Syndrome: A Retrospective Cohort Study"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1616-6641","authenticated-orcid":false,"given":"Imran","family":"Khan","sequence":"first","affiliation":[{"name":"Montfort Hospital, Ottawa, ON K1K 0T2, Canada"},{"name":"Faculty of Science, School of Pharmaceutical Sciences, University of Ottawa, Ottawa, ON K1H 8M5, Canada"},{"name":"Institut du Savoir Montfort, H\u00f4pital Montfort, Ottawa, ON K1K 0T2, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ariel","family":"Hendin","sequence":"additional","affiliation":[{"name":"Montfort Hospital, Ottawa, ON K1K 0T2, Canada"},{"name":"Institut du Savoir Montfort, H\u00f4pital Montfort, Ottawa, ON K1K 0T2, Canada"},{"name":"Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada"},{"name":"Ottawa Hospital, Ottawa, ON K1Y 4E9, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bernadett","family":"Kovacs","sequence":"additional","affiliation":[{"name":"Montfort Hospital, Ottawa, ON K1K 0T2, Canada"},{"name":"Institut du Savoir Montfort, H\u00f4pital Montfort, Ottawa, ON K1K 0T2, Canada"},{"name":"Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dominic","family":"Seguin","sequence":"additional","affiliation":[{"name":"Montfort Hospital, Ottawa, ON K1K 0T2, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caitlin","family":"Richler","sequence":"additional","affiliation":[{"name":"Montfort Hospital, Ottawa, ON K1K 0T2, Canada"},{"name":"Faculty of Science, School of Pharmaceutical Sciences, University of Ottawa, Ottawa, ON K1H 8M5, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christine","family":"Landry","sequence":"additional","affiliation":[{"name":"Montfort Hospital, Ottawa, ON K1K 0T2, Canada"},{"name":"Faculty of Science, School of Pharmaceutical Sciences, University of Ottawa, Ottawa, ON K1H 8M5, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pierre","family":"Thabet","sequence":"additional","affiliation":[{"name":"Montfort Hospital, Ottawa, ON K1K 0T2, Canada"},{"name":"Faculty of Science, School of Pharmaceutical Sciences, University of Ottawa, Ottawa, ON K1H 8M5, Canada"},{"name":"Institut du Savoir Montfort, H\u00f4pital Montfort, Ottawa, ON K1K 0T2, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"788","DOI":"10.1001\/jama.2016.0291","article-title":"Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries","volume":"315","author":"Bellani","year":"2016","journal-title":"JAMA"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Huang, D., Ma, H., Xiao, Z., Blaivas, M., Chen, Y., Wen, J., Guo, W., Liang, J., Liao, X., and Wang, Z. (2018). Diagnostic value of cardiopulmonary ultrasound in elderly patients with acute respiratory distress syndrome. BMC Pulm. Med., 18.","DOI":"10.1186\/s12890-018-0666-9"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1164\/rccm.202311-2011ST","article-title":"An update on management of adult patients with acute respiratory distress syndrome: An official American Thoracic Society clinical practice guideline","volume":"209","author":"Qadir","year":"2024","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1177\/0310057X20978981","article-title":"Patient-ventilator dyssynchrony in the intensive care unit: A practical approach to diagnosis and management","volume":"49","author":"Oto","year":"2021","journal-title":"Anaesth. Intensive Care"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2079","DOI":"10.1097\/CCM.0000000000002027","article-title":"Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient","volume":"44","author":"Murray","year":"2016","journal-title":"Crit. Care Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1328","DOI":"10.1097\/00003246-199608000-00010","article-title":"Critical illness polyneuropathy: Clinical findings and outcomes of a frequent cause of neuromuscular weaning failure","volume":"24","author":"Hund","year":"1996","journal-title":"Crit. Care Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"174","DOI":"10.2165\/00003088-199631030-00002","article-title":"Clinical pharmacokinetics of rocuronium bromide","volume":"31","author":"Sparr","year":"1996","journal-title":"Clin. Pharmacokinet."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1186\/s40560-020-00455-2","article-title":"Neuromuscular blockade management in the critically ill patient","volume":"8","author":"Renew","year":"2020","journal-title":"J. Intensive Care"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"27","DOI":"10.2165\/00003088-199936010-00003","article-title":"Clinical pharmacokinetics of cisatracurium besilate","volume":"36","author":"Kisor","year":"1999","journal-title":"Clin. Pharmacokinet."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1997","DOI":"10.1056\/NEJMoa1901686","article-title":"Early neuromuscular blockade in the acute respiratory distress syndrome","volume":"380","author":"Moss","year":"2019","journal-title":"N. Engl. J. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1007\/s00134-023-07050-7","article-title":"ESICM guidelines on acute respiratory distress syndrome: Definition, phenotyping and respiratory support strategies","volume":"49","author":"Grasselli","year":"2023","journal-title":"Intensive Care Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"2648","DOI":"10.1097\/00003246-199912000-00007","article-title":"Paralysis in the critically ill: Intermittent bolus pancuronium compared with continuous infusion","volume":"27","author":"Carr","year":"1999","journal-title":"Crit. Care Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1186\/s40560-023-00696-x","article-title":"Prolonged use of neuromuscular blocking agents is associated with increased long-term mortality in mechanically ventilated medical ICU patients: A retrospective cohort study","volume":"11","author":"Lin","year":"2023","journal-title":"J. Intensive Care"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"942","DOI":"10.1002\/j.1875-9114.1996.tb03013.x","article-title":"A pharmacoeconomic analysis of neuromuscular blocking agents in the operating room","volume":"16","author":"Loughlin","year":"1996","journal-title":"Pharmacotherapy"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1107","DOI":"10.1056\/NEJMoa1005372","article-title":"Neuromuscular blockers in early acute respiratory distress syndrome","volume":"363","author":"Papazian","year":"2010","journal-title":"N. Engl. J. Med."},{"key":"ref_16","unstructured":"Canadian Pharmaceutical Distribution Network (CPDN) (2025, December 19). Cisatracurium Besylate Product Pricing and Availability; Rocuronium Bromide Product Pricing and Availability. Available online: https:\/\/www.cpdn.ca."}],"container-title":["Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2079-9721\/14\/1\/22\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,6]],"date-time":"2026-01-06T11:27:33Z","timestamp":1767698853000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2079-9721\/14\/1\/22"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,6]]},"references-count":16,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["diseases14010022"],"URL":"https:\/\/doi.org\/10.3390\/diseases14010022","relation":{},"ISSN":["2079-9721"],"issn-type":[{"value":"2079-9721","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,6]]}}}