Please select the eligibility criteria that correspond to the clinical trial below.
Title: Systematic Early Use of Neuromuscular Blocking Agents in ARDS Patients
Brief Summary: The use of neuromuscular blocking agents (NMBA) in ARDS patients has not been extensively investigated. The aim of the study is to show a reduction of the mortality rate of ARDS patients.


Options:
A: Inclusion Criteria:

1. Patients admitted to any of the five intensive care units
2. Older than 18 years
3. Nutritional risk screening score (NRS) higher or equal to three upon ICU admission

Exclusion Criteria:

1. Patients with a do not resuscitate (DNR) code or moribund at the time of ICU admission
2. Patients already enrolled in another trial
3. Patients transferred from another intensive care unit with an established nutritional therapy
4. Patients suffering from ketoacidotic or hyperosmolar coma on admission
5. Patients with a body mass index (BMI) below 17 kg/m\^2
6. Short bowel syndrome
7. Patients known to be pregnant or nursing
8. Patients on mechanical ventilation at home
9. NRS score lower than three
10. Patient readmitted to ICU after randomization to the EPaNIC trial.
11. Patient not critically ill on admission. (No clinical indication for central intravenous catheter or patient ready for oral nutrition on admission.)
B: Inclusion Criteria:

Critically ill patients with failure of at least 2 organ systems diagnosed with SIRS or sepsis fulfilling the following inclusion criteria will be included in this study.

1. Age Range: 18 - 80 years
2. written information and consent as early as possible
3. Male and female patients
4. Clinical signs of incipient CIPNM:

   * decreased tendon reflexes as compared to the admission examination at the ICU
   * or weakness in responsive and co-operative patients as compared to the ad-mission examination at the ICU
   * or signs of incipient muscular atrophy as compared to the admission examination at the ICU

Organ failure:

Patients have to meet at least two of the following 5 criteria:

* cardiovascular system dysfunction: arterial systolic blood pressure\<90mm Hg, or mean arterial pressure \< 70mm Hg for at least one hour despite adequate fluid resuscitation, adequate intravascular volume status or the use of vasopressors in an attempt to maintain a systolic blood pressure \>90mm Hg or a mean arterial pressure \>70mm Hg.
* kidney dysfunction: Urine output \< 0,5ml/kg body weight/ hour for 1 hour, despite adequate fluid resuscitation
* respiratory system dysfunction: Ratio of PaO2 to FiO2 \< 250 in the presence of other dysfunctional organs or systems
* hematologic dysfunction: Platelet count \<80.000/mm3 or decreased by 50% in the 3 days preceding enrollment (in the absence of liver cirrhosis or previously known hematological disease)
* metabolic dysfunction: In case of unexplained metabolic acidosis - pH\<7,30 or base deficit \>5.0mmol/ litre in association with a plasma lactate level \>1,5 times of the upper normal limit

SIRS:

Patients have to meet at least three of the following four criteria:

* core temperature \>38 or \<36°C
* heart rate \>90 beats /min, except medical conditions known to increase heart rate
* respiratory rate \>20 breaths/min or a PaCO2 of \<32mm Hg or the use of mechanical ventilation for an acute respiratory process
* a white- cell count of\>12.000 cells/mm3 or \<4.000 cells/mm3 or a differential count showing \>10% immature neutrophils

Sepsis:

Known or suspected infection evidenced by one or more of the following:

* white cells or bacteria in a normally sterile body fluid
* perforated viscus
* radiographic evidence of pneumonia in the association with the production of purulent sputum
* a syndrome associated with a high risk of infection

Exclusion Criteria:

The inclusion criteria have to be met at the time of enrolment into the study, i.e. at the start of the baseline period. Patients with any of the following conditions will be excluded from the study:

1. Age \< 18 years or \> 80 years
2. Weight \>135 kg
3. Pregnancy or breast-feeding
4. Patients with known absolute IgA-deficiency with proven antibody formation against IgA
5. Patients with known IVIG-intolerability
6. Patients with known pre-existing neuromuscular disorders will not be included. Patients with documented pre-existing severe polyneuropathy will be excluded.
7. Patients with known diseases of the peripheral nerval system and patients with pre-existing disease of the central nerval system with relevant impairment of the motor function.
8. Patients with relevant pulmonary edema secondary to severe heart failure will be excluded because of the relatively high infusion volume (5ml /kg body weight per day over 3 days) determined by the study medication
9. Patients not expected to survive 28 days because of uncorrectable medical condition, such as poorly controlled neoplasma or other end-stage disease
10. Moribund state in which death is perceived to be imminent
11. HIV infection in association with a last known CD4 count of\<50/mm3
12. Prediction, based on clinical judgement, that the patient will require chronic ventilatory support for non-respiratory reasons (e.g. neuromuscular disease, paraplegia
C: Inclusion Criteria:

* 1 day of mechanical ventilation with an expectation of requiring ≥2 additional days of ICU stay in a Johns Hopkins Intensive Care Unit (ICU)

Exclusion Criteria:

* Unable to understand or speak English due to language barrier or cognitive impairment prior to admission
* Unable to independently transfer from bed to chair at baseline prior to hospital admission
* Known primary systemic neuromuscular disease (e.g. Guillian-Barre) at ICU admission
* Known intracranial process that is associated with localizing weakness (e.g. cerebral vascular accident) at ICU admission
* Transferred from another ICU outside of the Johns Hopkins system after \>4 consecutive days of mechanical ventilation
* Moribund (i.e. \>90% probability of patient mortality in the next 96 hours)
* Anticipated transfer to another ICU for care (e.g. awaiting organ transplantation and transfer to surgical ICU)
* Any pacemaker (e.g., cardiac, diaphragm) or implanted cardiac defibrillator
* Pregnancy
* Body mass index ≥35 kg/m2
* Any limitation in life support other than a sole no-CPR order
* Known or suspected malignancy in the legs
* Unable to treat or evaluate both lower extremities (e.g., bilateral amputation, bilateral skin lesions)
* ICU length of stay \>7 days prior to enrollment
D: Inclusion Criteria:

* ARDS with a PaO2 / FiO2 \< 150 with a PEEP \> 5 since less than 48 hrs
* informed consent

Exclusion Criteria:

* NMBA allergy
* Continuous administration of NMBA for ARDS prior inclusion
* Age \< 18 yrs
* SAPS II \> 70
* Persistent air leak

Answer: D