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Introduction: Nondepolarizing neuromuscular blockade (NDMB) is a key intervention to avoid ventilation-induced lung injury in acute respiratory distress syndrome (ARDS). In patients with moderatesevere ARDS associated with SARS-CoV-2 infection (CARDS), NDMB were used for prolonged periods of time, with high cumulative doses. We hypothesize that administration of NDMB might contribute to an increased incidence of risk factors later associated with long COVID-19. Method(s): We designed a non-interventional, retrospective study in a large university urban hospital. From January to December 2021, data related to prescription of NDMB, respiratory physiology, mechanical ventilation (IMV) and clinical outcomes were collected from patients' electronic records with a diagnosis of CARDS. Primary outcome was day-90 mortality. Secondary outcomes were ICU length of stay (LOS), ICU-acquired weakness and days of IMV. Mann-Whitney U test was used to compare continuous variables and logistic regression was used to evaluate the association of NDMB use with outcomes, adjusted or not for confounders. Result(s): 116 patients diagnosed with CARDS were included, 87% with severe ARDS and overall mortality was 37.1%. Median age was 57 years (IQ:47-67) and 65.5% were male. P:F ratio at day-1 was 86 (IQ:43). Ventilator-free days (VFDs) at 28 days was 13 (IQ:0-19) in survivors and ICU-LOS was 19 (IQ:10-36). Median time and cumulative dose of NDMB were, respectively, 117 h and 1177.468 mg in patients who survived (n = 70) compared to 197 h and 1898.775 mg in patients who died (n = 41). In addition to days of NDMB exposure (OR 1.05, CI 95% 1.00-1.11), the cumulative dose of cisatracurium, expressed in logs, was correlated with risk of mortality in the ICU, with odds ratio 1.49 (CI 95% 1.08-2.04). Conclusion(s): Patients with severe forms of CARDS received prolonged infusions of NDMB, with high cumulative doses. Both time of exposure and total doses were independently associated with higher risk of mortality.
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BACKGROUND: Nutrition support is an essential part of critical care medicine. It is commonly accepted that for the critically ill patient, enteral nutrition (EN) is favored. For the patient who receives neuromuscular blockades, EN may be held, or initiation delayed, because of concerns for EN intolerance. We hypothesized there would be no difference in EN tolerance between groups receiving cisatracurium while receiving EN compared with those not receiving cisatracurium. METHODS: This was a retrospective study that included 459 patients from a combined medical and surgical intensive care unit. There were 44 patients who received cisatracurium with EN and 415 who received EN alone. Data collected included gastric residual volume (GRV) and emesis occurrences, new-onset abdominal pain, new or worsening abdominal distention, and bowel ischemia. RESULTS: There were more patients with new or worsening abdominal distention in the group receiving cisatracurium (31.82% vs 14.94%; P < 0.01) as well as occurrences of GRV > 300 ml (P < 0.01). There was no statistically significant difference between the groups regarding emesis, new-onset abdominal pain, or bowel ischemia. CONCLUSION: Our findings suggest that it is acceptable to provide patients with EN who are receiving cisatracurium.
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SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Malignant hyperthermia (MH) is a hypermetabolic crisis where an increase in carbon dioxide is seen despite an increased minute ventilation with a proposed mechanism as a disturbance in calcium homeostasis. Commonly seen in volatile anesthetic agents and depolarizing neuromuscular blockers, rarely with nondepolarizing agents. There has been one reported case of cisatracurium-induced MH in the setting of ARDS. There have been two cases reported of nondepolarizing neuromuscular agents causing MH in the setting of COVID-19. CASE PRESENTATION: A 34-year-old man with severe COVID-19 complicated by ARDS on ventilator day 16, due to refractory fevers, ventilatory dyssynchrony, high minute ventilation and auto-PEEP phenomena, the decision was made to attempt neuromuscular paralysis. After one dose of cisatracurium, the patient became hyperthermic and end-tidal carbon-dioxide increased from 58-98 with inability to oxygenate. The patient developed high peak pressures, bedside ultrasound revealed no evidence of pneumothorax also confirmed with chest x-ray. The patient then received a dose of dantrolene with end-tidal improving to 60 and tachycardia also resolved. A creatinine kinase level drawn was elevated at 571. DISCUSSION: A proposed mechanism of MH is calcium release from sarcoplasmic reticulum, a mutation in skeletal muscle ryanodine receptor calcium release channels that can release IL-6 when activated leading to excessive muscular contraction. Proinflammatory cytokine IL-6, dantrolene may block IL-6 release which results in its therapeutic effect in the treatment of MH. IL-6 has been used to predict deterioration from COVID-19. Dantrolene in this sense has been proposed as a potential therapeutic agent against COVID-19, inhibiting intracellular calcium influx thus preventing the pathological feedback of viral entry into cells via endocytosis, as this is a calcium dependent process. Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of MH, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. CONCLUSIONS: Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of malignant hyperthermia, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. Reference #1: Sathyanarayanan SP, Hamza M, Hamid K, Groskreutz D. Cisatracurium-Associated Malignant Hyperthermia During Severe Sars-CoV-2 Infection. Am J Ther. 2021 Aug 10;28(5):e590-e591. doi: 10.1097/MJT.0000000000001437. PMID: 34387563;PMCID: PMC8415506. Reference #2: Chiba N, Matsuzaki M, Mawatari T, Mizuochi M, Sakurai A, Kinoshita K. Beneficial effects of dantrolene in the treatment of rhabdomyolysis as a potential late complication associated with COVID-19: a case report. Eur J Med Res. 2021 Feb 8;26(1):18. doi: 10.1186/s40001-021-00489-8. PMID: 33557936;PMCID: PMC7868892. Reference #3: Han H, Ma Q, Li C, Liu R, Zhao L, Wang W, Zhang P, Liu X, Gao G, Liu F, Jiang Y, Cheng X, Zhu C, Xia Y. Profiling serum cytokines in COVID-19 patients reveals IL-6 and IL-10 are disease severity predictors. Emerg Microbes Infect. 2020 Dec;9(1):1123-1130. doi: 10.1080/22221751.2020.1770129. PMID: 32475230;PMCID: PMC7473317. DISCLOSURES: No relevant relationships by Hira Bakhtiar No relevant relationships by Timothy DAmico no disclosure on file for Sarah Margolskee;No relevant relationships by Carlos Merino No relevant relationships by Joanna Moore
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The proceedings contain 246 papers. The topics discussed include: nasotracheal vs orotracheal intubation and post-extubation airway obstruction in critically ill children: an open-label randomized controlled trial;prognostication of the outcomes in patients on mechanical ventilation due to severe ARDS in COVID-19 using neutrophil to lymphocyte ratio (NLR) at admission;prognostic role of different severity indexes in COVID-19 pneumonia: a retrospective study;monoclonal antibody for COVID treatment;fluid management 100% non-invasive for COVID patient in ICU by sterling stroke volume guided resuscitation;post-COVID double valve and bypass surgery one of 1st in world;terlipressin-induced skin necrosis;safety, feasibility, and outcome of percutaneous dilatational tracheostomy in critically ill COVID-19 Patients;Cisatracurium for Orgen failure patient in ICU;and is there association between trends of inflammatory marker to clinical course of critically ill COVID-19 patient require prolong hospitalization?.
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INTRODUCTION: Critically ill adult patients requiring extracorporeal membrane oxygenation (ECMO) with prolonged paralytic exposure may develop potential tachyphylaxis. This phenomenon has yet to be described within the ECMO literature. DESCRIPTION: A 49-year-old male (70 kg) with hyperlipidemia and recently diagnosed COVID19, was admitted to the ICU for acute respiratory distress syndrome, intubated and paralyzed, and subsequently initiated on VV ECMO. By day 20, his sedation and paralytic regimen consisted of the following: hydromorphone 6 mg/hr, midazolam 12 mg/hr, phenobarbital IV 120 mg twice daily, and cisatracurium 12 mcg/kg/min, which was gradually increased from 5 mcg/kg/min from the previous 7 days. Propofol use was limited because of hypertriglyceridemia. Despite this, he was dyschronous with the ventilator and had 4/4 twitches on a train of four (TOF), with stable hemodynamics. A recommendation was made to stop cisatracurium and switch to rocuronium given concern for paralytic tachyphylaxis. The cisatracurium drip was stopped and the patient was loaded with a 1.2 mg/ kg (85 mg) rocuronium bolus using total body weight (TBW), followed by an 8 mcg/kg/min infusion. After 24 hours of use, the patient was more synchronous, had 0/4 twitches on a TOF, and did not require any escalation in the rocuronium infusion rate. This effect persisted for several days thereafter. DISCUSSION: This case highlights the phenomenon of paralytic tachyphylaxis in the ECMO population and sheds light on pharmacokinetic (PK) considerations. While the specific mechanism of resistance is not clearly understood, case reports in non-ECMO patients suggest that the likelihood of tachyphylaxis increases with high doses (≥12 mcg/kg/min) and prolonged use (> 7 days). Management included stopping the initial paralytic and switching to an alternative agent. Rocuronium is a hydrophilic drug with limited protein binding. Given this PK profile, we anticipated that the degree of sequestration in the ECMO circuit would be relatively low. Following our experience, we concluded that the switch to rocuronium was safe and effective in minimizing tachyphylaxis. Dosing of rocuronium may be similar to non- ECMO patients and should be guided by ventilator synchrony and TOF monitoring.