Shannon Kuhrau, PharmD
Loyola University Medical Center
Maywood, Illinois
Disclosure information not submitted.
Kevin Chang, PharmD, BCCCP
Surgical/Trauma Intensive Care Unit Clinical Pharmacist
Loyola University Medical Center, United States
Disclosure information not submitted.
John Lyons, PharmD, BCPS
Lung Transplant Pharmacist
Loyola University Medical Center, United States
Disclosure information not submitted.
Title: Impact of neuromuscular blockade infusion duration in patients with moderate to severe ARDS
Introduction:
Acute Respiratory Distress Syndrome (ARDS) is an acute respiratory condition in which neuromuscular blocking agents (NMBAs) have been used to prevent respiratory dyssynchrony and reduce oxygenation consumption. Landmark trials examining NMBA use in moderate to severe ARDS continued paralytics in the intervention group for 48 hours, however in clinical practice the duration is often extended due to clinical patient factors. The objective of this study was to determine how duration of NMBAs impact mechanical ventilation duration in moderate to severe ARDS.
Methods:
Retrospective cohort study of moderate to severe ARDS patients (P:F ratio < 150 mmHg) who received cisatracurium from January 2015 through December 2019. Patients were divided into groups based on use of NBMA for £48 hours and >48 hours. Primary outcome was duration of mechanical ventilation and secondary outcomes included 7-, 28- and 90-day mortality, ICU and hospital length of stay, change in P:F ratio and incidence of ICU acquired weakness. Factors associated with increased mechanical ventilation were analyzed using multivariable linear regression.
Results:
A total of 266 patients were analyzed, of which 69 were included. Of these, 32 were continued on NMBA for £48 hours and 37 were continued for >48 hours. Baseline characteristics were similar between groups with the notable exception of APACHE II scores and use of inhaled of epoprostenol which were higher in the >48-hour group. Continuation of NMBAs past 48 hours did not demonstrate any difference in mechanical ventilation duration (15 ± 9.5 vs. 16.1 ± 7.4 days, p=0.72), 90-day mortality (46.9% vs. 48.6%, n=0.98), or ICU length of stay (18.5 [10-27] vs. 18 [8-28] days, p=0.76). The incidence of ICU acquired weakness was numerically higher in the >48-hour group but did not meet statistical significance (37.5% vs. 51.4%, p=0.25). The multivariable linear regression demonstrated that no baseline demographics impacted duration of mechanical ventilation and a Kaplan Meier survival analysis demonstrated no difference between groups in survival trend.
Conclusion:
Continuation of NMBAs for greater than 48 hours was not associated with any clinical benefit. Potential risks of prolonged NMBA use exist, specifically ICU acquired weaknesses, which should be considered in NMBA use.