ABSTRACT
SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: The use of neuromuscular blocking agents (NMBA) has been trialed in acute respiratory distress syndrome (ARDS) to decrease patient–ventilator desynchrony, decrease work of breathing and improve oxygenation. No consistent reduction in mortality or ventilator free days has been demonstrated. The use of NMBA’s can be associated with neuromuscular weakness and adverse cardiovascular events. The use of NMBA’s increased significantly in our ICU after the advent of COVID-19, partly related to the increase incidence of ARDS observed, but also because of the seemingly increased ventilator asynchrony seen in this patient population. Our group evaluated the use of NMBA infusions in our medical intensive care unit (MICU) and subsequently implemented a “Paralytic initiation decision bundle” to decrease the frequency (and duration) of NMBA infusions by optimizing conditions before initiating an NMBA. METHODS: We conducted a retrospective cohort evaluation of the pattern of NMBA usage in our MICU from December 2020 to May 2021 at the Memorial Hermann Hospital-Texas Medical Center. Patients were excluded if they were on ECMO or if the NMBA infusions were initiated at an outside hospital. We then started an NMBA initiation bundle to decrease the overuse of this intervention. RESULTS: Forty-four patients were initiated on an NMBA infusion during the preintervention period (average 7.3 patients/month). This cohort included 63% males, an average age of 59.7 years (SD +/- 13.3), with 81.8% diagnosed with COVID-19. 54.5% were started on a paralytic drip <24 hours after intubation, 11.4% between 24 and 48 hours and 34.1% were started on a paralytic drip >48 hours after intubation (mean 7.5 days;range of 3-15 days). 27 patients (61.4%) were noted to be on an NMBA infusion for greater than 48 hours. The average duration of continuous paralytic infusion in this group was 5.2 days (SD +/- 3.1;range of 3-16 days). After a paralytic bundle was implemented, the use of NMBAs dropped significantly (2 patients/month) with an average infusion duration of <48 hours. CONCLUSIONS: The use of NMBA’s for greater than 48 hours in patients with ARDS is not currently recommended. The extended use of paralytics is seen often in COVID-19 ARDS patients. The implementation of a paralytic bundle with alternatives for sedation, optimization of alternative ARDS treatment strategies and a mandatory stop (or reevaluation) of NMBA after 48 hours resulted in a reduction in paralytic use at our institution. Limitations of this study include the decrease in COVID-19 cases during the intervention (hence restricting the evaluation of the tool). We plan to continue to investigate the intervention and add to our current data. Further studies are also needed to investigate the optimal use of paralytics in COVID-19 ARDS. CLINICAL IMPLICATIONS: The use of an NMBA bundle in patient’s with ARDS can help reduce the overuse of this intervention. DISCLOSURES: No relevant relationships by Jennifer Cortes No relevant relationships by Kimberly DSouza No relevant relationships by Galyna Ivashchuk No relevant relationships by Ruckshanda Majid No relevant relationships by Zachary Pinchover No relevant relationships by Oriana Salamo