Cisatracurium in Coronavirus Disease 2019 and Moderate-to-Severe Acute Respiratory Distress Syndrome

ABSTRACT

INTRODUCTION: Acute respiratory distress syndrome (ARDS) develops in approximately 33% of hospitalized coronavirus disease 19 (COVID-19) patients with 75% of COVID-19-related intensive care unit (ICU) admissions caused by an ARDS diagnosis. Currently, there is conflicting evidence regarding the mortality benefit of early neuromuscular blocking agents (NMBAs) being used in moderate-to-severe ARDS, and data is especially lacking in COVID-19-related ARDS despite increased NMBA utilization. This study aims to assess if early versus late initiation of a cisatracurium infusion in critically ill COVID-19 adults with moderate-to-severe ARDS has an effect on 28- day breathing without assistance. METHOD(S) Retrospective cohort study conducted at a multi-hospital community health system between March 2020 and November 2021. Eligible patients included adults >= 18 years, admitted to the ICU with COVID-19 infection and moderate-to-severe ARDS requiring mechanical ventilation, and received a cisatracurium infusion for at least four hours. Patients were divided into two groups early (within 48 hours) versus late (greater than 48 hours) initiation of cisatracurium infusion from the time of mechanical ventilation. RESULT(S) A total of 118 patients were included in the final analysis. At day 28, there were no significant differences in the rate of breathing without assistance between the early and late group (15.3% and 10.2%, respectively;p = 0.407). Similarly, there were no significant differences between groups in all-cause mortality or death in the ICU at day 28. Intensive care unit length of stay was significantly shorter among the early group with a median of 10.6 days versus 15.1 days in the late group (p = 0.028). Additionally, mechanical ventilation duration was significantly shorter in the early group compared to the late group (median, 7.3 and 11.6 days, respectively;p = 0.001). Incidence of barotrauma during cisatracurium infusion did not differ between groups. CONCLUSION(S) Early initiation of a cisatracurium continuous infusion was not associated with a significant improvement in breathing without assistance at day 28 in moderate-to-severe ARDS patients with COVID-19. The utilization and timing of cisatracurium in this patient population remains uncertain.