ABSTRACT
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 electronicallyadministered 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 trainof- 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.
ABSTRACT
Introduction: Mechanically ventilated COVID-19 patients have unusually high requirements for analgesics and sedatives compared to non-COVID 19 patients, and the need for higher dosages coupled with prolonged infusions can contribute to critical drug shortages. In an attempt to preserve the limited supply of the injectable formulations at our institution, use of enteral opioids and benzodiazepines was implemented. Research Question or Hypothesis: To evaluate potential differences in clinical effect and analgesic/sedative usage between two groups of mechanically ventilated COVID-19 patients based on route of administration: IV+enteral versus IV alone. Study Design: Retrospective cohort study Methods: This IRB-approved study evaluated ventilation time and fentanyl or midazolam usage when used concurrently with enteral hydromorphone and lorazepam. Inclusion criteria: 18-89 years old patients admitted to ICU with positive SARS-CoV-2 RT-PCR or antigen test and respiratory failure requiring invasive mechanical ventilation for >72 hours. Exclusion criteria: pregnancy or breast-feeding, and chronic opioid or benzodiazepine use within 30 days prior to admission. Data were collected in Microsoft Excel for initial analyses with subsequent inferential testing (Student's t-tests) performed using STATA® 13.1, College Station, TX. Significance for all testing was defined as alpha less than 0.05. Results: One hundred patients were evaluated, 55 in IV+enteral group and 45 in IV only group. There was no significant difference in ventilation time between two groups (20.7±13 vs. 16.5±12 days, p=0.1068). However, there was a statistically significant increase in fentanyl (1869.2±850.5 vs. 2281.6±853.4, p=0.0002) and midazolam (126±76.7 vs. 148.9±77.2, p=0.0061) requirements on day 3 in IV alone group and increase in fentanyl requirements when compared to IV+enteral group (33±842 vs.-412.4±673.6, p= 0.0050). Conclusion: Duration of mechanical ventilation in patients with COVID-19 is not reduced with combined IV+enteral compared to IV only analgesics/sedatives, but the combination may reduce IV analgesic requirements ameliorating the impact of IV shortages.