Journal Article

Early short course of neuromuscular blocking agents in patients with COVID-19 ARDS: a propensity score analysis

Shrapnel, Sally, Brodie, Daniel, Panigada, Mauro, Ichiba, Shingo, Gibbons, Kristen, Hinton, Samuel, Burrell, Aidan, Forsyth, Simon, Ng, Pauline Yeung, Ogino, Mark, Li Bassi, Gianluigi, Fan, Eddy, Laffey, John G., Esperatti, Mariano, Chiumello, Davide, Marwali, Eva, Pelosi, Paolo, Suen, Jacky Y., Torres, Antoni, Fanning, Jonathon P., Fraser, John F., White, Nicole, Merson, Laura, Elhazmi, Alyaa, Luna, Carlos, Dalton, Heidi J., Nichol, Alistair, Bartlett, Robert, Grasselli, Giacomo, Hodgson, Carol, Corley, Amanda, Murthy, Srinivas

2022

Overview

Background The role of neuromuscular blocking agents (NMBAs) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) is not fully elucidated. Therefore, we aimed to investigate in COVID-19 patients with moderate-to-severe ARDS the impact of early use of NMBAs on 90-day mortality, through propensity score (PS) matching analysis. Methods We analyzed a convenience sample of patients with COVID-19 and moderate-to-severe ARDS, admitted to 244 intensive care units within the COVID-19 Critical Care Consortium, from February 1, 2020, through October 31, 2021. Patients undergoing at least 2 days and up to 3 consecutive days of NMBAs (NMBA treatment), within 48 h from commencement of IMV were compared with subjects who did not receive NMBAs or only upon commencement of IMV (control). The primary objective in the PS-matched cohort was comparison between groups in 90-day in-hospital mortality, assessed through Cox proportional hazard modeling. Secondary objectives were comparisons in the numbers of ventilator-free days (VFD) between day 1 and day 28 and between day 1 and 90 through competing risk regression. Results Data from 1953 patients were included. After propensity score matching, 210 cases from each group were well matched. In the PS-matched cohort, mean (± SD) age was 60.3 ± 13.2 years and 296 (70.5%) were male and the most common comorbidities were hypertension (56.9%), obesity (41.1%), and diabetes (30.0%). The unadjusted hazard ratio (HR) for death at 90 days in the NMBA treatment vs control group was 1.12 (95% CI 0.79, 1.59, p  = 0.534). After adjustment for smoking habit and critical therapeutic covariates, the HR was 1.07 (95% CI 0.72, 1.61, p  = 0.729). At 28 days, VFD were 16 (IQR 0–25) and 25 (IQR 7–26) in the NMBA treatment and control groups, respectively (sub-hazard ratio 0.82, 95% CI 0.67, 1.00, p  = 0.055). At 90 days, VFD were 77 (IQR 0–87) and 87 (IQR 0–88) (sub-hazard ratio 0.86 (95% CI 0.69, 1.07; p  = 0.177). Conclusions In patients with COVID-19 and moderate-to-severe ARDS, short course of NMBA treatment, applied early, did not significantly improve 90-day mortality and VFD. In the absence of definitive data from clinical trials, NMBAs should be indicated cautiously in this setting.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Acute respiratory distress syndrome / Aged / Coronaviruses / COVID-19 / COVID-19 - drug therapy / Critical care / Critical Care Medicine / Diabetes / Drug therapy / Emergency Medicine / Female / Humans / Intensive / Intensive care unit / Intensive Care Units / Male / Mechanical ventilation / Medicine / Medicine & Public Health / Middle Aged / Mortality / Neuromuscular blocking agent / Neuromuscular blocking agents / Neuromuscular Blocking Agents - therapeutic use / Patient outcomes / Propensity Score / Respiration, Artificial / Respiratory Distress Syndrome - drug therapy / Risk factors / SARS-CoV-2 / Severe acute respiratory syndrome coronavirus 2 / Ventilators