Papazian and colleagues reported lower mortality (NNT ~10) with a 48-hour infusion of high dose cisatracurium (ED95) versus heavy sedation in patients with moderate to severe ARDS (PMID: 20843245). The ROSE trial examined the same dose/duration of cisatracurium versus a lower sedation approach for a similar ARDS population (PMID: 31112383). Both ROSE arms received the same mechanical ventilation strategies including a higher PEEP strategy. ROSE enrolled 1006 patients early after onset of moderate-to-severe ARDS (median: 7.6 hours). During the first 48 hours, 97.4%) patients in the intervention group received cisatracurium (median duration: 47.8 hours; median dose: 1807 mg), whereas 17.0%) of patients in the control group received neuromuscular blockade (median dose: 38 mg, usually bolus dosing). The primary endpoint of 90-day all-cause in-hospital mortality was 42.5% and 42.8% in the intervention and control groups (difference: -0.3 percentage points, 95% CI: -6.4% to 5.9%, p=0.93). The intervention group was less physically active and developed more cardiovascular adverse events while in hospital. There were no consistent between-group differences in long term outcomes assessed at three, six, and twelve months. The reasons for the discordant results between these two studies are unclear and may lie in differences in the control arms, as will be discussed in this presentation. Based on the ROSE trial results, for patients with moderate-to-severe ARDS managed with a higher PEEP and a lower sedation strategy, routine use of an early and continuous cisatracurium infusion is not recommended.