ARDS and refractory hypoxaemia

Neuromuscular blockade and fluid management

Reviewed Nov 2026·5 references
New· views rounded down, updated weekly

Use a 24-48 h cisatracurium infusion in early severe ARDS if asynchrony or high pressures persist despite deep sedation. After shock resolves, use a conservative fluid strategy with diuretics to reduce lung water.

At the bedside

Timed steps
  1. 1

    Early severe ARDS

    Consider NMB

    P/F < 150 with persistent ventilator dyssynchrony, double triggering, or Pplat/driving pressure above target despite deep sedation. Not routine.

  2. 2

    Sedate deeply first

    Start

    RASS -5 before paralysis (awareness risk); then cisatracurium bolus and infusion for up to 48 h.

  3. 3

    During NMB

    Monitor

    Train-of-four, eye care, pressure areas, DVT prophylaxis, glucose; daily reassess the need. Avoid steroids + NMB for long periods (weakness).

  4. 4

    Shock phase

    Fluids

    Resuscitate shock appropriately; no restriction during shock.

  5. 5

    After shock

    Fluids

    Conservative strategy: aim even to negative balance; furosemide if CVP or clinical overload and perfusion adequate (FACTT).

  6. 6

    Selected

    Albumin

    Albumin + furosemide in hypoalbuminaemic patients may improve oxygenation (small trials).

NMB in early severe ARDS

Cisatracurium

IV bolus then infusion
Dose
0.15-0.2 mg/kg bolus, then 1-3 mcg/kg/min (ACURASYS: 15 mg then 37.5 mg/h)
Range
1–3 mcg/kg/min
Preparation
Undiluted 2 mg/mL
Worked example
70 kg × 2 mcg/kg/min = 140 mcg/min = 8.4 mg/h ÷ 2 mg/mL = 4.2 mL/h
Open infusion calculator

Alternative NMB

Atracurium

IV bolus then infusion
Dose
0.5 mg/kg bolus, then 5-10 mcg/kg/min
Preparation
250 mg in 50 mL = 5 mg/mL
Worked example
70 kg × 6 mcg/kg/min = 420 mcg/min = 25.2 mg/h ÷ 5 = 5 mL/h
Open infusion calculator

Conservative fluid strategy

Furosemide

IV
Dose
20-40 mg bolus or 5-20 mg/h infusion
Red flag · call your senior now
Paralysed patient with tachycardia and hypertension: inadequate sedation (awareness).
Pitfall
Using NMB to mask a ventilator setting problem that could be fixed.
Pitfall
Prolonged infusions beyond 48 h without daily review.
Pearl
In ROSE (lighter sedation controls), early NMB did not reduce mortality; reserve for those who need it.

Calculators for this topic

Infusion rate from mcg/kg/min

Pump rate in mL/h for drugs dosed in mcg/kg/min (noradrenaline, adrenaline, dobutamine, milrinone, nitroglycerin by weight).

References

  1. 1

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

  2. 2

    National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. Early neuromuscular blockade in the acute respiratory distress syndrome (ROSE). N Engl J Med. 2019;380(21):1997-2008

  3. 3

    Qadir N, Sahetya S, Munshi L, et al. An update on management of adult patients with acute respiratory distress syndrome: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2024;209(1):24-36

  4. 4

    National Heart, Lung, and Blood Institute ARDS Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury (FACTT). N Engl J Med. 2006;354(24):2564-2575

  5. 5

    Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023;49(7):727-759

Test yourself

Module quiz · score 70% to complete the module

Previous

Prone positioning

Next

Corticosteroids and pharmacological adjuncts

Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.