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.
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.
Brian Erstad, BCPS, PharmD, MCCM
Professor & Head
University of Arizona College of Pharmacy
Tucson, Arizona
Disclosure information not submitted.
Title: Critical Care Pharmacist Attitudes and Perceptions of Neuromuscular Blocker Infusions in ARDS
INTRODUCTION: In the face of the COVID pandemic, and recent evidence and practice guidelines surrounding neuromuscular infusion (NMBI) use during ARDS, the practices/perceptions of ICU pharmacists regarding NMBI use during ARDS may not be evidence-based.
Methods: We developed, tested, and electronically-administered a questionnaire (9 questions/68 subquestions) to 409 members of the ACCP Critical Care PRN residing in 12 geographically-diverse U.S. states. 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). Reminders were sent twice at 10-day intervals.
Results: Respondents [131/409(32%)] primarily worked in a medical ICU 102(78%) and were BCCCP-certified 82(63%). COVID+ patients were twice as likely to receive a NMBI (34±18 vs.16±17%;P< 0.01). Respondents somewhat/strongly agreed an NMBI: should be reserved until after a trial of deep sedation 116(86%) or proning 92(81%); be dose-titrated based on train-of-four monitoring 71(54%); and effectively reduces barotrauma 88(67%) and dyssynchrony 87(66%). Few respondents [23(18%)] somewhat/strongly agreed a NMBI should be initiated at ARDS onset or administered at fixed-doses [17(13%]). Only 2/14 potential NMBI risks were frequently reported to be of high/very high concern: awareness of paralysis due to inadequate sedation 101(82%) and prolonged muscle weakness during steroids 84(68%). Many potential NMBI titration targets were assessed to be very/extremely important: arterial pH 109(88%), dyssynchrony 197(86%), PaO2:FiO2 82(66%), and RASS assessment 80(65%); train-of-four 55(44%) and BIS 36(29%) monitoring were deemed less important. Absence of dysschrony 84(69%) and use ≥48 hr 72(60%) were preferred NMBI stopping criteria. For COVID+ ARDS patients, few respondents felt any of the following were very/extremely important reasons for NMBI initiation: reduced self-extubation and COVID aerosolization exposure during reintubation 8(6%) or reduced sedative use during shortages 8(6%).
Conclusions: Most pharmacists agree NMBI infusions in ARDS are best reserved until after trials of deep sedation or proning. Awareness of paralysis and prolonged muscle weakness are the greatest NMBI-use concerns. Unique considerations in COVID+ ARDS patients exist.