John Devlin, BCCCP, PharmD, MCCM
Professor
Northeastern University
Boston, Massachusetts, United States
Disclosure information not submitted.
Sarah Train, MD
Fellow, Division of Pulmonary/Crit Care Medicine
Brigham and Women's Hospital, United States
Disclosure information not submitted.
Karen Burns, MD, FRCPS
Associate Professor
Saint Michael's Hospital
Toronto, Ontario, Canada
Disclosure information not submitted.
Brian Erstad, BCPS, PharmD, MCCM
Professor & Head
University of Arizona College of Pharmacy
Tucson, Arizona
Disclosure information not submitted.
Anthony Massaro, MD
Director, Medical ICU
Brigham and Women's Hospital, Massachusetts, United States
Disclosure information not submitted.
John Vasseur, MD
Fellow, Division of Pulmonary/Crit Care Medicine
University of Arizona Medical Center, United States
Disclosure information not submitted.
Kavitha Selvan, MD
Fellow, Division of Pulmonary/Crit Care Medicine
University of Chicago Hospitals, United States
Disclosure information not submitted.
John Kress, MD
Professor of Medicine
University of Chicago, United States
Disclosure information not submitted.
Title: Physicians’ Attitudes and Perceptions of Neuromuscular Blocker Infusions in ARDS
Introduction: With the COVID pandemic, and recently updated practice guidelines for neuromuscular infusion (NMBI) use during ARDS, the practices/perceptions of ICU physicians regarding NMBI use during ARDS may not be evidence-based.
Methods: We developed, tested, and electronically-administered a questionnaire (9 questions/70 subquestions) to medical and surgical ICU fellow and attending physicians at 3 geographically-diverse U.S. health systems (U Arizona, U Chicago, Mass General Brigham). The IRB-approved questionnaire focused on adults with moderate-severe ARDS (PaO2:FiO2 < 150) with critical hypoxemia where dyssynchrony causes were addressed and PEEP optimized. Weekly reminders were sent twice.
Results: Respondents [173/342(50.5%)] primarily worked as an attending 117(75%) in a medical ICU 94(60%) for 12±8 weeks/year. COVID+ ARDS patients were twice as likely to receive a NMBI (56±37 vs. 28±19%; p< 0.01). Respondents somewhat/strongly agreed a NMBI: should be reserved until after a trial of deep sedation 142 (82%) or proning 59 (34%), be dose-titrated based on train-of-four monitoring 107(62%); and effectively reduced dyssynchrony 149(86%), plateau pressure 106(62%) and barotrauma 102(60%). Few respondents [23(18%)] somewhat/strongly agreed a NMBI should be initiated at ARDS onset 20(12%) or administered at a fixed-dose 12(7%). Only 2/14 potential NMBI risks were frequently reported to be of high/very high concern: prolonged muscle weakness during steroids 135(79%) and paralysis awareness due to inadequate sedation 114(67%). Only absence of dyssynchrony 146(87%) was frequently reported to be a very/extremely important NMBI titration target. Train-of-four 78(46%) and BIS 39(23%) monitoring and plateau pressure 67(40%) or PaO2:FiO2 64(38%) evaluation were deemed less important. Absence of dysschrony 93(56%) and use ≥48 hours 87(53%) were preferred NMBI stopping criteria. For COVID+ patients, few felt reduced self-extubation and COVID aerosolization during reintubation 16(9%) or reduced ventilator adjustments 7(5%) were very/extremely important reasons for NMBI use.
Conclusions: Most physicians agree NMBI infusions in ARDS should be reserved until after trials of deep sedation. Paralysis awareness and prolonged muscle weakness are the greatest NMBI use concerns. Unique considerations in COVID+ ARDS patients exist.