ABSTRACT
INTRODUCTION: Limited data exist to support the use of rocuronium continuous infusions in the intensive care unit (ICU). Due to a shortage of cisatracurium, our Pharmacy and Therapeutics committee approved the use of rocuronium as a therapeutic alternative. The objective of this study was to evaluate the dosing and monitoring of adult patients who received rocuronium for hypoxemic respiratory failure during the COVID-19 pandemic. METHODS: This was a prospective, single-center study from March 1, 2020 to May 31, 2020. We identified all adult patients admitted to any ICU who received rocuronium via continuous infusion. Patients were excluded if they received rocuronium for < 6 hours. Study subjects could have multiple paralysis infusions during the same admission. Each rocuronium infusion was separated by at least 24 hours. The main outcome of this study was the relationship between the hourly administration rate of rocuronium and TOF assessment by using Pearson correlation coefficient. Secondary outcomes of this study included median rocuronium dose at initiation, duration of infusion, and median rate of infusion. TOF results were classified as over-paralyzed (TOF = 0), wellparalyzed (TOF = 1-2), or under-paralyzed (TOF = 3-4). RESULTS: Seventy-one patients and 97 paralysis infusions were included. Fifty-nine patients (83%) were positive for SARS CoV-2. There was a negligible correlation between the dose of rocuronium and the TOF results (r = 0.04). Of the 97 paralysis infusions, the median dose at initiation was 3 [3-5] mcg/kg/min and duration of infusion was 45 [23.6-92.5] hours. The median rate of infusion was 4.3 [2.8-7.2] mcg/kg/ min. A total of 1775 TOFs were assessed, of which 46.2% were over-paralyzed, 35.7% well-paralyzed, and 18.1% under-paralyzed. CONCLUSIONS: We found no correlation between rocuronium dose and TOF assessments. The initial and maintenance infusion doses in our analysis were lower than what have been previously referenced. As TOF is unpredictable, patients initiated on continuous infusion rocuronium may be started at lower doses while being titrated to ventilator synchrony to avoid over-paralysis.
ABSTRACT
INTRODUCTION: Inhaled epoprostenol (iEPO) and nitric oxide (iNO), have been shown to improve oxygenation in patients with refractory hypoxemia and ARDS. The purpose of this analysis was to evaluate the efficacy and safety of iEPO and iNO in patients with COVID-19 and refractory hypoxemia. METHODS: This retrospective cohort study evaluated critically ill patients admitted to the ICU with respiratory failure secondary to COVID-19 from March to June 2020. Patients were included if they received at least one hour of iEPO or iNO for refractory hypoxemia. The primary outcome was the change in the partial pressure of oxygen [PaO2]/fractional concentration of oxygen [FiO2] ratio following initiation of iEPO or iNO. Secondary outcomes included changes in PaO2 and pulse oxygen saturation (SpO2), percentage of patients classified as ?responders? (increase PaO2/FiO2 > 10%), differences between responders and non-responders, and adverse events. Logistic regression was used to determine predictors of responsiveness to iEPO. RESULTS: Of 93 patients screened, 38 were included in the analysis, with mild (4, 10.5%), moderate (24, 63.2%) or severe (10, 26.3%) ARDS. All patients were initiated on iEPO as the initial pulmonary vasodilator and the median time from intubation to initiation was 137 (68 to 228) hours. The median change in PaO2/FiO2 was 0 (-12.8 to 31.6) immediately following administration of iEPO. Sixteen patients (42.1%) were classified as responders with a median increase in PaO2/FiO2 of 34.1 (24.3 to 53.9) with iEPO. The mean change in PaO2 and SpO2 was -0.55 ± 41.8 and -0.6 ± 4.7, respectively. Eleven patients transitioned to iNO with a median change of 11 (3.6 to 24.8) in PaO2/FiO2. No differences in outcomes or characteristics were seen between responders and non-responders. Minimal adverse events were seen in patients who received either iEPO or iNO. CONCLUSIONS: We found that the initiation of iEPO and iNO in patients with refractory hypoxemia secondary to COVID-19, on average, did not produce significant increases in oxygenation metrics. However, a small group of patients had significant improvement with iEPO and iNO.
ABSTRACT
INTRODUCTION: Propofol 1%, available as an oilin- water emulsion, is an attractive sedative option in patients with COVID-19 since it is rapid acting and easily titratable. Previous studies have shown approximately 18% to 45% of patients who receive propofol in the ICU develop hypertriglyceridemia, depending on the definition. Additionally, various reports have recently described hypertriglyceridemia without a clear etiology in patients infected with SARS-CoV-2. The objective of this analysis was to report the incidence of, and evaluate risk factors for, hypertriglyceridemia in patients with COVID-19 who received propofol. METHODS: This was a retrospective, observational analysis in SARS-CoV-2 positive patients who received propofol for at least four hours from March 1, 2020 to April 20, 2020. Patients were excluded if transferred from an outside hospital with propofol administered for > 24 hours, had zero triglyceride levels drawn during admission, or had acute pancreatitis on admission. Hypertriglyceridemia was defined as any triglyceride level ≥ 400 mg/dL. Univariate and multivariate analyses were performed to evaluate risk factors for hypertriglyceridemia. RESULTS: A total of 128 patients were screened, of which 106 patients were included in the analysis. Sixty patients (56.6%) met criteria for hypertriglyceridemia, with a median time to development of 46 hours. A total of five patients had clinical suspicion of acute pancreatitis, with one patient having confirmatory imaging. There was no difference in the dose (8.1 g vs. 6.8 g;p = 0.2) or duration (171 hr vs. 162 hr;p = 0.7) of propofol in patients who developed hypertriglyceridemia. Patients who developed hypertriglyceridemia had significantly increased levels of ferritin, CRP, and d-dimer compared to those who did not develop hypertriglyceridemia. CONCLUSIONS: Hypertriglyceridemia was commonly observed in critically ill patients with COVID-19 who received propofol. Neither the cumulative dose nor duration of propofol were identified as a risk factor for the development of hypertriglyceridemia. Due to the incidence of hypertriglyceridemia in this patient population, monitoring of serum triglyceride levels should be done frequently in patients who require more than 24 hours of propofol.