Janci Addison, PharmD
PGY2 Pharmacy Resident
Ascension Seton
Austin, Texas, United States
Disclosure information not submitted.
Emily Hodge, PharmD, BCCCP
Clinical Pharmacy Specialist, Critical Care
Ascension Seton, United States
Disclosure information not submitted.
Mitchell Daley, BCCCP, PharmD, FCCM
Clinical Pharmacist Specialist Critical Care
Seton Family Healthcare, University of Texas
Austin, Texas
Disclosure information not submitted.
Molly Curran, PharmD, BCCCP, BCPS
Clinical Pharmacy Manager
Ascension Seton, United States
Disclosure information not submitted.
Title: Sedative Choice in Acute Respiratory Distress Syndrome Patients Requiring Neuromuscular Blockade
Introduction: Continuous infusion (CI) neuromuscular blocking agents (NMBA) are commonly used to improve ventilation compliance in acute respiratory distress syndrome (ARDS). Guidelines recommend deep sedation prior to and during NMBA use. It is not known whether non-benzodiazepines are associated with improved outcomes in this population as has been demonstrated in the general ICU population. The purpose of this study is to compare the efficacy and safety of propofol and midazolam in ARDS patients requiring CI NMBA.
Methods: This retrospective cohort study includes mechanically ventilated adult patients requiring CI NMBA for management of ARDS within seven days of ICU admission between December 2013 and September 2020. The primary outcome was to compare the time to liberation from MV in patients sedated with propofol compared to midazolam after NMBA discontinuation (DC). Secondary outcomes included time to achieve therapeutic sedation goal, time to emergence from sedation after NMBA DC, ICU LOS, and mortality. Safety outcomes included incidence of delirium, hypotension, bradycardia, hypertriglyceridemia, and use of rescue medications.
Results: A total of 109 patients were included. Eighty-one patients met the primary outcome of MV liberation. The other 28 patients were censored in the primary analysis, but included in secondary analyses. Propofol monotherapy was given in 40 patients and midazolam monotherapy was given in 69 patients. There was no significant difference in median time to MV liberation in patients sedated with propofol as compared with midazolam (121 hr (Interquartile range (IQR) 243.5) vs 98 hr (IQR 126.87), p=0.72). Median time to emergence from sedation after NMBA DC was significantly shorter in patients receiving propofol (12.9 hr (IQR 53) vs 31.5 hr (IQR 435), p < 0.01). There was no significant difference in other secondary outcomes.
Conclusions: There is no difference between propofol and midazolam in the time to liberation from MV in ARDS patients receiving CI NMBA. However, propofol has a faster time to emergence from deep sedation, which in previous studies has shown to have better long term outcomes in the general ICU population.