Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient

Australian clinical practice guideline for physical rehabilitation and mobilisation in adult intensive care units

BACKGROUND

The evidence base for research on physical rehabilitation and mobilisation in the intensive care unit has led to uncertainty about best practice.

OBJECTIVE

The objective of this guideline was to develop evidence-based recommendations to support clinical decision-making for physical rehabilitation management of adults undergoing invasive mechanical ventilation in Australian intensive care units.

METHODS

The guideline development group, comprising national representation of clinical experts, methodologists, and consumers, followed a rigorous process, adhering to Australian National Health and Medical Research Council Guidelines for Guidelines, to create the recommendations. The guideline development group determined the scope of the guideline and defined the key clinical question. A systematic review was conducted to evaluate all available evidence based on the predefined outcomes. Meta-analyses were performed using a restricted maximum likelihood approach, and results were summarised in an evidence profile. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence, and the GRADE Evidence to Decision framework was used to formulate recommendations.

SUMMARY OF RECOMMENDATIONS

Based on the evidence profile and GRADE Evidence to Decision framework, the group developed three conditional recommendations and 14 Good Clinical Practice statements to guide practice. The guideline provides conditional recommendations in favour of undertaking physical rehabilitation and mobilisation in adults receiving invasive mechanical ventilation in the intensive care unit whilst acknowledging the uncertainty of evidence. It was endorsed by four key professional organisations.

CONCLUSION

The recommendations within this guideline were developed following best methodological practice. Despite the overall low certainty of evidence, the resulting guideline provides support to clinical decision-making, facilitates the translation of research into practice, and enhances the reach and impact of clinical research. Additionally, the guideline development group identified evidence gaps that could be addressed by future research.

TRIAL REGISTRATION

Not applicable.

The association between non-depolarizing neuromuscular blockade agents and survival to discharge in dogs undergoing mechanical ventilation: a multi-center retrospective study of 227 dogs (2010-2020)

Objective

To evaluate the association between neuromuscular blockade agent (NMBA) use and outcome in dogs undergoing mechanical ventilation (MV), including survival to discharge, and complications.

Methods

The medical records for 227 mechanically ventilated dogs were reviewed for NMBA use, parameters of respiratory status (PaO2, PCO2, PF ratio, SpO2), MV settings, MV complications, and survival outcome.

Results

The NMBA and non-NMBA groups included 28 and 199 dogs, respectively. The median partial pressures of oxygen in arterial blood (PaO2) in the NMBA and non-NMBA groups were 63 and 57 mmHg, respectively (P = 0.24). The median partial pressures of blood carbon dioxide levels were 58 and 51 mmHg, respectively (P = 0.07). The pulse oximetry percentage (SpO2) prior to initiation of MV were 88 and 94%, respectively (P = 0.02). The median PF ratios prior to MV were 90 and 215, respectively (P = 0.02). The median durations of MV were 18 and 24 h, respectively (P = 0.32). Eight (28.6%) dogs that received NMBAs survived to discharge, while 51 dogs (32.3%) that did not receive NMBAs survived to discharge (P = 0.87). Both PF ratio and SpO2 values were significantly lower in dogs that received NMBAs compared to dogs that did not (P = 0.02 and P = 0.02, respectively). There was no significant difference in tidal volume or peak inspiratory pressure at the time of MV initiation (P = 0.17 and P = 0.09, respectively). There was no significant difference between the incidence of complications in dogs that received NMBAs and those that did not (P = 0.08).

Conclusion

This study revealed no statistical significance between NMBA use and survival or complications. However, dogs in the NMBA group likely had more severe hypoxemia than the non-NMBA group, as indicated by their lower PF ratios and SPO2 values prior to initiation of mechanical ventilation. The similarities in survival rate between the NMBA and non-NMBA patient populations, despite higher severity of respiratory pathology in the NMBA group, may suggest a potential therapeutic benefit to NMBA use for MV patients. Further investigation into the use of NMBAs in patients undergoing MV are warranted.

Development of an evidence-based nursing practice program for preventing unplanned endotracheal extubations in the intensive care unit: A Delphi method study

AIMS

This study aims to develop an evidence-based nursing practice program to prevent unplanned endotracheal extubation (UEE) among adult patients in the intensive care unit (ICU).

DESIGN

This study uses the Delphi method to develop an evidence-based nursing practice program.

METHODS

A comprehensive review of 18 databases and evidence-based websites was conducted to gather, assess and synthesize evidence on preventing UEEs in adult patients. Using this synthesized evidence, a questionnaire was formulated for further investigation. Subsequently, input was solicited from experts through Delphi surveys to establish an evidence-based nursing practice protocol for preventing UEEs in adult ICU patients. Consistency in consultation results guided subsequent rounds of consultation.

RESULTS

The developed program comprised 43 evidence items categorized into nine dimensions, including risk assessment for unplanned extubation, sedation, analgesia, delirium, balloon management, psychosocial care, early extubation, catheter immobilization and protective restraints. Two rounds of expert inquiry yielded recovery rates of 94.7% and 100% for the first and second questionnaires, respectively. Kendall W values ranged from .224 to .353 (p < .001).

CONCLUSION

This study developed an evidence-based nursing practice program to prevent UEE in adult ICU patients, employing evidence-based practices and Delphi expert consultation methods. However, further validation of the program's effectiveness is warranted.

REPORTING METHOD

Findings were reported according to the Standards for Reporting Qualitative Research checklist.

PATIENT OR PUBLIC CONTRIBUTION

Nurses contributed to the study by participating in investigations.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The program developed in this study offers an evidence-based framework for preventing unplanned extubation in hospitals, thereby reducing its incidence and enhancing the quality of nursing care.

Management of Asthma and COPD Exacerbations in Adults in the ICU

Severe, life-threatening asthma and COPD exacerbations are managed commonly in the ICU and are associated with significant morbidity and mortality. It is important to understand the commonalities and differences in the diagnosis and management of these obstructive lung diseases to improve patient outcomes via evidence-based care. In this review, we first outline triggers of acute asthma and COPD exacerbations and an initial diagnostic evaluation and severity assessment. We then review the pathophysiologic features of asthma and COPD exacerbations and create a framework for the management of exacerbations in critically ill adult patients aimed at reducing airway inflammation, reversing bronchospasm, and, in severe cases, supporting patients with mechanical ventilation or advanced therapies until clinical improvement is achieved.

Neuromuscular monitoring: A tutorial for pharmacists

PURPOSE

To describe neuromuscular monitoring modalities and highlight the importance of neuromuscular monitoring to clinical pharmacy practice.

SUMMARY

A growing body of literature and clinical practice guidelines have highlighted the importance of neuromuscular monitoring practices to ensure patient safety during surgery and in the intensive care unit. Understanding neuromuscular monitoring modalities can allow pharmacists to enhance participation in institutional discussions and optimization of neuromuscular blocker administration and reversal practices. We have described the various modalities of neuromuscular monitoring and considerations for using different modalities.

CONCLUSION

Neuromuscular monitoring should be performed whenever neuromuscular blocking agents are administered. This practice represents an evidence-based approach to minimizing the occurrence of residual neuromuscular blockade and its associated complications.

Development of evidence-based standards for inpatient physiotherapy services: a systematic review and content analysis of clinical practice guidelines

OBJECTIVE

Performance standards are critical to service design and quality improvement. There are no published standards defining the care inpatients should receive from physiotherapists in Aotearoa New Zealand. This study aims to explore the potential of using clinical practice guidelines (CPGs) to develop a set of evidence-based standards for physiotherapy in inpatient settings.

DESIGN

A systematic review and content analysis of CPGs.

DATA SOURCES

Scholarly databases (Web of Science, CINAHL and Scopus, PEDro) and grey literature (guideline databases - NICE, SIGN, ECRI guideline trust, Guidelines International Network (GIN)) were searched between July and September 2021.

ELIGIBILITY CRITERIA

CPGs related to conditions and treatments common to physiotherapy in a secondary care setting were included. Mental health conditions, paediatrics, COVID-19 and conditions common to tertiary care were excluded.

DATA EXTRACTION AND SYNTHESIS

A pragmatic approach was taken to group guidelines aligned with common physiotherapy services and select only the most recent and comprehensive guidelines for final analysis. The quality of CPGs was assessed using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II). Data from guideline recommendations of relevance to inpatient physiotherapy were grouped into themes. Summative 'statements' were drafted to represent the content of each theme; these were given a confidence rating based on the number of supporting guidelines and the strength or grade of evidence awarded by the guideline group.

RESULTS

The recommendations of 32 CPGs yielded 27 statements.

CONCLUSION

Twenty-seven statements represent a distillation of the best evidence-based practice recommendations from CPGs in inpatient physiotherapy. Statements of physiotherapy dosage (frequency, intensity and duration) are not available for many areas of practice; researchers and CPG groups should consider the importance of these data for service commissioning.  .

Evaluation of Response to Weight-based Dosing Strategies of Continuous, Fixed-Rate Atracurium Infusions in Critically Ill, Obese Adults With Acute Respiratory Distress Syndrome

BACKGROUND

Fixed-rate infusions of weight-based neuromuscular blocking agents (NMBAs) were adopted during the COVID pandemic to limit caregiver exposure during titrations. Although fixed-rate infusions are supported in studies of acute respiratory distress syndrome (ARDS), the optimal scalar for weight-based NMBAs in patients with obesity remains controversial.

OBJECTIVE

This study sought to compare change in oxygenation using two weight-based dosing strategies for atracurium in obese patients with ARDS. Secondary outcomes included total atracurium dose, mortality, and intensive care unit (ICU) and ventilator-free days.

METHODS

Following an institutional practice update to use ideal body weight (IBW) for patients with obesity, we retrospectively compared adults (≥18 years) with ARDS and a body mass index (BMI) ≥ 30 kg/m2 who received atracurium (15 µg/kg/min) based on actual body weight (ABW) with those using IBW. The primary outcome was change in PaO2/FiO2 ratio (P/F) 48 hours after atracurium initiation. Analysis-of-covariance compared change in P/F between groups after adjustment for confounders.

RESULTS

The IBW group (n = 123), compared with the ABW group (n = 133), had lower baseline P/F (85.0 [71.0, 118.3] vs 93.3 [76.0, 128.3], P = 0.025) and sequential organ failure assessment (SOFA) score (9.7 ± 2.6 vs 10.5 ± 2.6, P = 0.015), with greater use of steroids (96% vs 89%, P = 0.032) and prone positioning (72% vs 58%, P = 0.015). No difference was detected in change in P/F at 48 hours (adjusted least squares mean [95% confidence interval, CI]: 55.8 [37.0, 74.5] vs 56.9 [39.6, 74.1], P = 0.90). Atracurium doses were higher in the ABW group (97.4 mg/h [84.4, 110.3] vs 55.4 [47.2, 65.7], P < 0.001). There was no difference in hospital mortality, ICU mortality, and ICU-free days or ventilator-free days.

CONCLUSION AND RELEVANCE

In patients with obesity with ARDS receiving fixed-rate atracurium infusions, the change in P/F at 48 hours did not differ based on weight. Atracurium dosed on IBW may use less total drug without compromising ability to improve oxygenation. This is the first study comparing the dosing weight used for continuous infusion atracurium in hospitalized, critically ill ARDS patients with obesity. Additional studies are warranted to optimize dosing in obese patients.

Neuromuscular Blockade in Adult Respiratory Distress Syndrome

Although current clinical practice guidelines have discordant conclusions, a judicious approach to using NMBA infusions may include reserving their use for patients with early severe ARDS who are already deeply sedated and for patients under light sedation who have significant ventilator dyssynchrony, despite attempts to adjust both ventilator settings and sedation requirements. Based on current evidence, the duration of NMBA use should be limited to 48 hours, whenever possible.

Acute respiratory distress syndrome: A review of ARDS across the life course

Acute respiratory distress syndrome (ARDS) is a multifactorial, inflammatory lung disease with significant morbidity and mortality that predominantly requires supportive care in its management. Although initially described in adult patients, the diagnostic definitions for ARDS have evolved over time to accurately describe this disease process in pediatric and, more recently, neonatal patients. The management of ARDS in each age demographic has converged in the application of lung-protective ventilatory strategies to mitigate the primary disease process and prevent its exacerbation by limiting ventilator-induced lung injury. However, differences arise in the preferred ventilatory strategies or adjunctive pulmonary therapies used to mitigate each type of ARDS. In this review, we compare and contrast the epidemiology, common etiologies, pathophysiology, diagnostic criteria, and outcomes of ARDS across the lifespan. Additionally, we discuss in detail the different management strategies used for each subtype of ARDS and spotlight how these strategies were applied to mitigate poor outcomes during the COVID-19 pandemic. This review is geared toward both clinicians and clinician-scientists as it not only summarizes the latest information on disease pathogenesis and patient management in ARDS across the lifespan but also highlights knowledge gaps for further investigative efforts. We conclude by projecting how future studies can fill these gaps in research and what improvements may be envisioned in the management of NARDS and PARDS based on the current breadth of literature on adult ARDS treatment strategies.

Comparison of Fixed Dosing vs Train of Four Titration of Cisatracurium in COVID-19 ARDS Patients

Background: Early neuromuscular blockade with cisatracurium has been associated with improved outcomes in moderate-severe acute respiratory distress syndrome (ARDS). Previous studies have demonstrated increased drug utilization without benefits in oxygenation using fixed dose cisatracurium compared to train-of-four (TOF) titration. Objective: We sought to compare a novel, lower fixed dose cisatracurium protocol to TOF titration evaluating the impact on PaO2:FiO2 ratio (P/F). Methods: We conducted a single-center retrospective cohort study comparing fixed dose cisatracurium to TOF titration. We included patients aged 18-89 treated for COVID-19 ARDS with a baseline P/F≤200 who received a cisatracurium infusion for ≥12 h. The primary outcome was change in P/F at 48 h from baseline. Secondary outcomes included change in P/F at 24 h and 7 days, need for mechanical ventilation at day 28, and cisatracurium utilization. Results: Analyses included 125 patients (fixed dose = 65, TOF = 60). Severe ARDS was common with a baseline median P/F of 73.7 vs 79.5, P = .133. The change in P/F at 48 h was larger in the TOF cohort in the adjusted analysis (24.9 vs 70.8, P < .005). The rate and total cumulative dose of cisatracurium were higher in the fixed dose cohort (5 vs 3 mcg/kg/min, P < .001; 1034 vs 612 mg, P < .001) despite similar infusion durations (44.1 h vs 48.5 h, P = .642). Conclusions: Patients in the TOF cisatracurium cohort had improved P/F at 48 h compared to the fixed dose cohort, while also using only 60% of the cumulative dose. Future directions should include analysis of the implications of increased cisatracurium exposure on patient outcomes.

Continuous Neuromuscular Blockade for Bronchopulmonary Dysplasia

OBJECTIVE

 Bronchopulmonary dysplasia (BPD) is the most common late morbidity for premature infants. Continuous neuromuscular blockade (CNMB) is suggested for the most unstable phase of BPD, despite no outcome data. We explored the association between duration of CNMB for severe BPD and mortality.

DESIGN

 Medical record review of children <5 years old admitted from 2016 to 2022 with BPD and one or more course of CNMB for ≥14 days.

RESULTS

 Twelve children received a total of 20 episodes of CNMB for ≥14 days (range 14-173 d) during their hospitalization. Most (10/12) were born at <28 weeks' gestation and most (11/12) with birth weight <1,000 g; 7/12 were of Black race/ethnicity. All were hospitalized since birth. Most (10/12) were initially transferred from an outside neonatal intensive care unit (ICU), typically after a >60-day hospitalization (9/12). Half (6/12) of them had a ≥60-day stay in our neonatal ICU before transferring to our pediatric ICU for, generally, ≥90 days (8/12). The primary study outcome was survival to discharge: 2/12 survived. Both had shorter courses of CNMB (19 and 25 d); only one child who died had a course ≤25 days. Just two infants had increasing length Z-scores during hospitalization; only one infant had a final length Z-score > - 2.

CONCLUSION

 In this case series of infants with severe BPD, there were no survivors among those receiving ≥25 days of CNMB. Linear growth, an essential growth parameter for infants with BPD, decreased in most patients. These data do not support the use of ≥25 days of CNMB to prevent mortality in infants with severe BPD.

KEY POINTS

· This is a case series of neuromuscular blockade for severe BPD.. · Neuromuscular blockade did not improve linear growth.. · Ten out of 12 infants who were on prolonged neuromuscular blockade died..

Assessing pain in paralyzed critically ill patients receiving neuromuscular blocking agents: A monocenter prospective cohort

INTRODUCTION

Given the absence of established recommendations for pain assessment in pharmacologically paralyzed Intensive-Care-Units (ICU) patients under Neuro-Muscular-Blocking Agents (NMBA), this study assessed the validity of various parameters for evaluating pain in this specific population.

PATIENTS AND METHODS

Four electrophysiological parameters (instant-Analgesia-Nociception-Index (ANI), Bispectral index (BIS), Heart Rate (HR) and Mean Arterial Blood Pressure (ABP)) and one clinical parameter (Behavioural-Pain-Scale (BPS)) were recorded during tracheal-suctioning in all consecutive ICU patients who required a continuous infusion of cisatracurium, before and just after paralysis recovery measured by Train-of-Four ratio. The validity of the five pain-related parameters was assessed by comparing the values recorded during different situations (before/during/after the nociceptive procedure) (discriminant-validity, primary outcome), and the effect of paralysis was assessed by comparing values obtained during and after paralysis (reliability, secondary outcome).

RESULTS

Twenty patients were analyzed. ANI, BIS, and HR significantly changed during the nociceptive procedure in both paralysis and recovery, while BPS changed only post-recovery. ANI and HR were unaffected by paralysis, unlike BIS and BPS (mixed-effect model). ANI exhibited the highest discriminant-validity, with values (min 0/max 100) decreasing from 71 [48-89] at rest to 41 [25-72] during tracheal suctioning in paralyzed patients, and from 71 [53-85] at rest to 40 [31-52] in non-paralyzed patients.

CONCLUSIONS

ANI proves the most discriminant parameter for pain detection in both paralyzed and non-paralyzed sedated ICU patients. Its significant and clinically relevant decrease during tracheal suctioning remains unaltered by NMBA use. Pending further studies on analgesia protocols based on ANI, it could be used to assess pain during nociceptive procedures in ICU patients receiving NMBA.

Potential Impact of Subphenotyping in Pharmacologic Management of Acute Respiratory Distress Syndrome

Background: Acute respiratory distress syndrome (ARDS) is an acute inflammatory process in the lungs associated with high morbidity and mortality. Previous research has studied both nonpharmacologic and pharmacologic interventions aimed at targeting this inflammatory process and improving ventilation. Hypothesis: To date, only nonpharmacologic interventions including lung protective ventilation, prone positioning, and high positive end-expiratory pressure ventilation strategies have resulted in significant improvements in patient outcomes. Given the high mortality associated with ARDS despite these advancements, interest in subphenotyping has grown, aiming to improve diagnosis and develop personalized treatment approaches. Data Collection: Previous trials evaluating pharmacologic therapies in heterogeneous populations have primarily demonstrated no positive effect, but hope to show benefit when targeting specific subphenotypes, thus increasing their efficacy, while simultaneously decreasing adverse effects. Results: Although most studies evaluating pharmacologic therapies for ARDS have not demonstrated a mortality benefit, there is limited data evaluating pharmacologic therapies in ARDS subphenotypes, which have found promising results. Neuromuscular blocking agents, corticosteroids, and simvastatin have resulted in a mortality benefit when used in patients with the hyper-inflammatory ARDS subphenotype. Therapeutic Opinion: The use of subphenotyping could revolutionize the way ARDS therapies are applied and therefore improve outcomes while also limiting the adverse effects associated with their ineffective use. Future studies should evaluate ARDS subphenotypes and their response to pharmacologic intervention to advance this area of precision medicine.

Adverse events related to neuromuscular blocking agents: a disproportionality analysis of the FDA adverse event reporting system

Background: Neuromuscular blocking agents (NMBAs) are primarily used during surgical procedures to facilitate endotracheal intubation and optimize surgical conditions. This study aimed to explore the adverse event signals of NMBAs, providing reference for clinical safety. Methods: This study collected reports of atracurium, cisatracurium, rocuronium, and vecuronium as primary suspect drugs in The US Food and Drug Administration Adverse Event Reporting System (FAERS) from the first quarter of 2004 to the third quarter of 2023. The adverse events (AEs) reported in the study were retrieved based on the Preferred Terms (PTs) of the Medical Dictionary for Regulatory Activities. In addition, we conducted disproportionality analysis on relevant reports using the reporting odds ratio (ROR) method and Bayesian confidence propagation neural network (BCPNN) method. A positive signal was generated when both algorithms show an association between the target drug and the AE. Results: A total of 11,518 NMBA-related AEs were reported in the FAERS database. The most AEs of rocuronium were collected. NMBA-related AEs involved 27 different system organs (SOCs), all of the four NMBAs had positive signals in "cardiac disorders," "immune system disorders," "respiratory, thoracic and mediastinal disorders" and "vascular disorders." At the PTs level, a total of 523 effective AEs signals were obtained for the four NMBAs. AEs labled in the instructions such as anaphylaxis (include anaphylactic reaction and anaphylactic shock), bronchospasm, respiratory arrest and hypotension were detected positive signals among all NMBAs. In addition, we also found some new AEs, such as ventricular fibrillation for the four NMBAs, hyperglycaemia for atracurium, kounis syndrome and stress cardiomyopathy for rocuronium, hepatocellular injury for cisatracurium, hyperkalaemia for vecuronium. To further investigated the AEs associated with serious clinical outcomes, we found that cardiac arrest and anaphylaxis were the important risk factors for death due to NMBAs. Conclusion: NMBA-related AEs have a significant potential to cause clinically severe consequences. Our study provides valuable references for the safety profile of NMBAs, and considering the limitations of the FAERS database, further clinical data are needed to validate the findings of this study.

Neuromuscular Blocking Agent Use in Critical Care Transport Not Associated With Intubation

OBJECTIVE

Variable indications exist for neuromuscular blocking agents (NMBAs) in the critical care transport setting beyond facilitation of intubation.

METHODS

This retrospective cohort study included adult patients (≥ 18 years) who underwent critical care transport from July 1, 2020, to May 2, 2023, and received NMBAs during transport that was not associated with intubation. The primary outcome was the indication for NMBA administration. Secondary outcomes included the characterization of NMBA use, mean Richmond Agitation Sedation Scale score before NMBA administration, sedation strategy used, and continuation of NMBAs within 48 hours of hospital admission.

RESULTS

One hundred twenty-six patients met the inclusion criteria. The most common indication for NMBA administration was ventilator dyssynchrony (n = 71, 56.4%). The majority of patients received rocuronium during transport (n = 113, 89.7%). The mean pre-NMBA Richmond Agitation Sedation Scale score was -3.7 ± 2.4. The most common sedation strategy was a combination of continuous infusion and bolus sedatives (76.2%). One hundred (79.4%) patients had sedation changes in response to NMBA administration. Seventy-two (57.1%) received NMBAs during the first 48 hours of their intensive care unit admission.

CONCLUSION

NMBAs were frequently administered for ventilator dyssynchrony and continuation of prior therapy. Optimization opportunities exist to ensure adequate deep sedation and reassessment of NMBA indication.

Neuromuscular blocking agents during targeted temperature management for out-of-hospital cardiac arrest patients

BACKGROUND

Neuromuscular blocking agents (NMBAs) can control shivering during targeted temperature management (TTM) of patients with cardiac arrest. However, the effectiveness of NMBA use during TTM on neurologic outcomes remains unclear. We aimed to evaluate the association between NMBA use during TTM and favorable neurologic outcomes after out-of-hospital cardiac arrest (OHCA).

MATERIALS AND METHODS

A multicenter, prospective, observational cohort study from 2019 to 2021. It included OHCA patients who received TTM after hospitalization. We conducted overlap weight propensity-score analyses after multiple imputation to evaluate the effect of NMBAs during TTM. The primary outcome was a favorable neurological outcome, defined as a cerebral performance category of 1 or 2 at discharge. Subgroup analyses were conducted based on initial monitored rhythm and brain computed tomography findings.

RESULTS

Of the 516 eligible patients, 337 received NMBAs during TTM. In crude analysis, the proportion of patients with favorable neurological outcome was significantly higher in the NMBA group (38.3% vs. 16.8%; risk difference (RD): 21.5%; 95% confidence interval (CI): 14.0% to 29.1%). In weighted analysis, a significantly higher proportion of patients in the NMBA group had a favorable neurological outcome compared to the non-NMBA group (32.7% vs. 20.9%; RD: 11.8%; 95% CI: 1.2% to 22.3%). In the subgroup with an initial shockable rhythm and no hypoxic encephalopathy, the NMBA group showed significantly higher proportions of favorable neurological outcomes.

CONCLUSIONS

The use of NMBAs during TTM was significantly associated with favorable neurologic outcomes at discharge for OHCA patients. NMBAs may have benefits in selected patients with initial shockable rhythm and without poor prognostic computed tomography findings.

Design, synthesis, and biological evaluation of new bis-benzylisoquinoline-based analogues as potential neuromuscular blocking agents

Neuromuscular blocking agents (NMBAs) are widely used in anesthesia for intubation and surgical muscle relaxation. Novel atracurium and mivacurium derivatives were developed, with compounds 18c, 18d, and 29a showing mivacurium-like relaxation at 27.27 nmol/kg, and 15b, 15c, 15e, and 15h having a shorter duration at 272.7 nmol/kg. The structure-activity and configuration-activity relationships of these derivatives and 29a's binding to nicotinic acetylcholine receptors were analyzed through molecular docking. Rabbit trials showed 29a has a shorter duration compared to mivacurium. This suggests that linker properties, ammonium group substituents, and configuration are crucial for NMBA activity and duration, with compound 29a emerging as a potential ultra-short-acting NMBA.

The depth of neuromuscular blockade is not related to chest wall elastance and respiratory mechanics in moderate to severe acute respiratory distress syndrome patients. A prospective cohort study

BACKGROUND

Data concerning the depth of neuromuscular blockade (NMB) required for effective relaxation of the respiratory muscles in ARDS are scarce. We hypothesised that complete versus partial NMB can modify respiratory mechanics.

METHOD

Prospective study to compare the respiratory mechanics of ARDS patients according to the NMB depth. Each patient was analysed at two times: deep NMB (facial train of four count (TOFC) = 0) and intermediate NMB (TOFC >0). The primary endpoint was the comparison of chest wall elastance (ELCW) according to the NMB level.

RESULTS

33 ARDS patients were analysed. There was no statistical difference between the ELCW at TOFC = 0 compared to TOFC >0: 7 cmH2O/l [5.7-9.5] versus 7 cmH2O/l [5.3-10.8] (p = 0.36). The depth of NMB did not modify the expiratory nor inspiratory oesophageal pressure (Pesexp = 8 cmH2O [5-9.5] at TOFC = 0 versus 7 cmH2O [5-10] at TOFC >0; (p = 0.16) and Pesinsp = 10 cmH2O [8.2-13] at TOFC = 0 versus 10 cmH2O [8-13] at TOFC >0; (p = 0.12)).

CONCLUSION

In ARDS, the relaxation of the respiratory muscles seems to be independent of the NMB level.

A Comparison of Midazolam and Propofol for Deep Sedation in Patients with Acute Respiratory Distress Syndrome Requiring Neuromuscular Blocking Agents

Purpose: The optimal agent for deep sedation in patients undergoing continuous infusion (CI) neuromuscular blocking agent (NMBA) use for acute respiratory distress syndrome (ARDS) is unknown. The purpose of this study is to compare the efficacy and safety of propofol and midazolam in ARDS patients requiring CI NMBA. Methods: A multi-center, retrospective study was performed in mechanically ventilated (MV) adult patients requiring CI NMBA for management of ARDS. The primary outcome was to compare the time to liberation from MV in patients sedated with propofol vs midazolam. Results: In the 109 patients included, there was no difference in time to MV liberation with propofol as compared to midazolam (121 hr [Interquartile range (IQR) 67 195] vs 98 hr [IQR 48, 292], P = .72). Median time to sedation emergence after NMBA discontinuation was shorter in patients receiving propofol (12.9 hr [IQR 19.8, 72.5] vs 31.5 hr [IQR 6.4, 34.6], P < .01). There were no significant differences in time to therapeutic sedation, ICU stay, mortality, and adverse events. Conclusion: Propofol may be an effective and safe alternative to midazolam for patients undergoing CI NMBA for ARDS. Additionally, patients receiving propofol may have a quicker return to light sedation after NMBA discontinuation.

Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases

The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.

Association between mechanical power and intensive care unit mortality in Korean patients under pressure-controlled ventilation

BACKGROUND

Mechanical power (MP) has been reported to be associated with clinical outcomes. Because the original MP equation is derived from paralyzed patients under volume-controlled ventilation, its application in practice could be limited in patients receiving pressure-controlled ventilation (PCV). Recently, a simplified equation for patients under PCV was developed. We investigated the association between MP and intensive care unit (ICU) mortality.

METHODS

We conducted a retrospective analysis of Korean data from the Fourth International Study of Mechanical Ventilation. We extracted data of patients under PCV on day 1 and calculated MP using the following simplified equation: MPPCV = 0.098 ∙ respiratory rate ∙ tidal volume ∙ (ΔPinsp + positive end-expiratory pressure), where ΔPinsp is the change in airway pressure during inspiration. Patients were divided into survivors and non-survivors and then compared. Multivariable logistic regression was performed to determine association between MPPCV and ICU mortality. The interaction of MPPCV and use of neuromuscular blocking agent (NMBA) was also analyzed.

RESULTS

A total of 125 patients was eligible for final analysis, of whom 38 died in the ICU. MPPCV was higher in non-survivors (17.6 vs. 26.3 J/min, P<0.001). In logistic regression analysis, only MPPCV was significantly associated with ICU mortality (odds ratio, 1.090; 95% confidence interval, 1.029-1.155; P=0.003). There was no significant effect of the interaction between MPPCV and use of NMBA on ICU mortality (P=0.579).

CONCLUSIONS

MPPCV is associated with ICU mortality in patients mechanically ventilated with PCV mode, regardless of NMBA use.

Neuromuscular blockade and oxygenation changes during prone positioning in COVID-19

PURPOSE

Neuromuscular blockers (NMBs) are often used during prone positioning to facilitate mechanical ventilation in COVID-19 related ARDS. However, their impact on oxygenation is uncertain.

METHODS

Multi-centre observational study of invasively ventilated COVID-19 ARDS adults treated with prone positioning. We collected data on baseline characteristics, prone positioning, NMB use and patient outcome. We assessed arterial blood gas data during supine and prone positioning and after return to the supine position.

RESULTS

We studied 548 prone episodes in 220 patients (mean age 54 years, 61% male) of whom 164 (75%) received NMBs. Mean PaO2:FiO2 (P/F ratio) during the first prone episode with NMBs reached 208 ± 63 mmHg compared with 161 ± 66 mmHg without NMBs (Δmean = 47 ± 5 mmHg) for an absolute increase from baseline of 76 ± 56 mmHg versus 55 ± 56 mmHg (padj < 0.001). The mean P/F ratio on return to the supine position was 190 ± 63 mmHg in the NMB group versus 141 ± 64 mmHg in the non-NMB group for an absolute increase from baseline of 59 ± 58 mmHg versus 34 ± 56 mmHg (padj < 0.001).

CONCLUSION

During prone positioning, NMB is associated with increased oxygenation compared to non-NMB therapy, with a sustained effect on return to the supine position. These findings may help guide the use of NMB during prone positioning in COVID-19 ARDS.

Findings of ventilator-measured P0.1 in assessing respiratory drive in patients with severe ARDS

BACKGROUND

Providers should adjust the depth of sedation to promote lung-protective ventilation in patients with severe ARDS. This recommendation was based on the assumption that the depth of sedation could be used to assess respiratory drive.

OBJECTIVE

To assess the association between respiratory drive and sedation in patients with severe ARDS by using ventilator-measured P0.1 and RASS score.

METHODS

Loss of spontaneous breathing was observed within 48 h of mechanical ventilation in patients with severe ARDS, and spontaneous breathing returned after 48 hours. P0.1 was measured by ventilator every 12 ± 2 hours, and the RASS score was measured synchronously.

RESULTS

The RASS score was moderately correlated with P0.1 (R𝑆𝑝𝑒𝑎𝑟𝑚𝑎𝑛, 0.570; 95% CI, 0.475 to 0.637; p= 0.00). However, only patients with a RASS score of -5 were considered to have no excessive respiratory drive, but there was a risk for loss of spontaneous breathing. A P0.1 exceeding 3.5 cm H2O in patients with other RASS scores indicated an increase in respiratory drive.

CONCLUSION

RASS score has little clinical significance in evaluating respiratory drive in severe ARDS. P0.1 should be evaluated by ventilator when adjusting the depth of sedation to promote lung-protective ventilation.

Current Practice Review in the Management of Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) presents as an acute inflammatory lung injury characterized by refractory hypoxemia and non-cardiac pulmonary edema. An estimated 10% of patients in the intensive care unit and 25% of those who are mechanically ventilated are diagnosed with ARDS. Increased awareness is warranted as mortality rates remain high and delays in diagnosing ARDS are common. The COVID-19 pandemic highlights the importance of understanding ARDS management. Treatment of ARDS can be challenging due to the complexity of the disease state and conflicting existing evidence. Therefore, it is imperative that pharmacists understand both pharmacologic and non-pharmacologic treatment strategies to optimize patient care. This narrative review provides a critical evaluation of current literature describing management practices for ARDS. A review of treatment modalities and supportive care strategies will be presented.

Enteral feeding tolerance during pharmacologic neuromuscular blockade

A common misperception is that critically ill patients who receive paralytic therapy will not tolerate enteral nutrition. As a result, some clinicians empirically withhold enteral feedings for critically ill patients who receive neuromuscular blocker pharmacotherapy (NMB). The intent of this review is to examine the evidence regarding enteral feeding tolerance for critically ill patients given NMB. Studies evaluating enteral feeding during paralytic therapy are provided and critiqued. Evidence examining enteral feeding tolerance during NMB is limited. Enteral feeding intolerance is more likely attributable to the underlying illnesses and concurrent opioid analgesia, sedation, and vasopressor therapies. Most critically ill patients can be successfully fed during NMB. Prokinetic pharmacotherapy may be warranted in some patients.

Prolonged use of neuromuscular blocking agents is associated with increased long-term mortality in mechanically ventilated medical ICU patients: a retrospective cohort study

BACKGROUND

Neuromuscular blockade agents (NMBAs) can be used to facilitate mechanical ventilation in critically ill patients. Accumulating evidence has shown that NMBAs may be associated with intensive care unit (ICU)-acquired weakness and poor outcomes. However, the long-term impact of NMBAs on mortality is still unclear.

METHODS

We conducted a retrospective analysis using the 2015-2019 critical care databases at Taichung Veterans General Hospital, a referral center in central Taiwan, as well as the Taiwan nationwide death registry profile.

RESULTS

A total of 5709 ventilated patients were eligible for further analysis, with 63.8% of them were male. The mean age of enrolled subjects was 67.8 ± 15.8 years, and the one-year mortality was 48.3% (2755/5709). Compared with the survivors, the non-survivors had a higher age (70.4 ± 14.9 vs 65.4 ± 16.3, p < 0.001), Acute Physiology and Chronic Health Evaluation II score (28.0 ± 6.2 vs 24.7 ± 6.5, p < 0.001), a longer duration of ventilator use (12.6 ± 10.6 days vs 7.8 ± 8.5 days, p < 0.001), and were more likely to receive NMBAs for longer than 48 h (11.1% vs 7.8%, p < 0.001). After adjusting for age, sex, and relevant covariates, the use of NMBAs for longer than 48 h was found to be independently associated with an increased risk of mortality (adjusted HR: 1.261; 95% CI: 1.07-1.486). The analysis of effect modification revealed that this association was tended to be strong in patients with a Charlson Comorbidity Index of 3 or higher.

CONCLUSIONS

Our study demonstrated that prolonged use of NMBAs was associated with an increased risk of long-term mortality in critically ill patients requiring mechanical ventilation. Further studies are needed to validate our findings.

Critical Care Pharmacist Attitudes and Perceptions of Neuromuscular Blocker Infusions in ARDS

BACKGROUND

Current critical care pharmacist (CCP) practices and perceptions related to neuromuscular infusion (NMBI) use for acute respiratory distress syndrome (ARDS) maybe different with the COVID-19 pandemic and the publication of 2020 NMBI practice guidelines.

OBJECTIVE

To evaluate CCP practices and perceptions regarding NMBI use for patients with moderate-severe ARDS.

METHODS

We developed, tested, and electronically administered a questionnaire (7 parent-, 42 sub-questions) to 409 American College of Clinical Pharmacy (ACCP) Critical Care Practice and Research Network members in 12 geographically diverse states. The questionnaire focused on adults with moderate-severe ARDS (PaO2:FiO2<150) whose causes of dyssynchrony were addressed. Two reminders were sent at 10-day intervals.

RESULTS

Respondents [131/409 (32%)] primarily worked in a medical intensive care unit (ICU) 102 (78%). Compared to COVID-negative(-) ARDS patients, COVID positive(+) ARDS patients were twice as likely to receive a NMBI (34 ± 18 vs.16 ± 17%; P < 0.01). Respondents somewhat/strongly agreed a NMBI should be reserved until after trials of deep sedation (112, 86%) or proning (92, 81%) and that NMBI reduced barotrauma (88, 67%), dyssynchrony (87, 66%), and plateau pressure (79, 60%). Few respondents somewhat/strongly agreed that a NMBI should be initiated at ARDS onset (23, 18%) or that NMBI reduced 90-day mortality (12, 10%). Only 2/14 potential NMBI risks [paralysis awareness (101, 82%) and prolonged muscle weakness (84, 68%)] were frequently reported to be of high/very high concern. Multiple NMBI titration targets were assessed as very/extremely important including arterial pH (109, 88%), dyssynchrony (107, 86%), and PaO2: FiO2 ratio (82, 66%). Train-of-four (55, 44%) and BIS monitoring (36, 29%) were deemed less important. Preferred NMBI discontinuation criteria included absence of dysschrony (84, 69%) and use ≥48 hour (72, 59%).

CONCLUSIONS AND RELEVANCE

Current critical care pharmacists believe NMBI for ARDS patients are best reserved until after trials of deep sedation or proning; unique considerations exist in COVID+ patients. Our results should be considered when ICU NMBI protocols are being developed and bedside decisions regarding NMBI use in ARDS are being formulated.

Gasping in Dying Children: Health Care Professionals' Feelings and Knowledge

Purpose: To assess the feelings and knowledge of health care professionals (HCPs) about gasping in dying patients in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs). Methods: A 9-item questionnaire addressed to 488 HCPs (physicians, nurses, and nursing assistants) of 2 NICUs and 2 PICUs. Questions were about HCPs' feelings when confronted with gasping, their knowledge, and their opinions on what to tell family members. Results: Responses were obtained from 248 staff members. Of the respondents, 43% felt that gasping was painful to the patient and most felt that witnessing gasps was distressing for the parents, and 77% reported being distressed by witnessing gasps. Conclusions: Efforts are needed to educate HCPs about the physiology of gasping, to help them to cope with gasping, and to give better support to parents.

Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents III: The 2023 Geneva revision

The set of guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents was developed following an international consensus conference in Copenhagen in 1996 (Viby-Mogensen et al., Acta Anaesthesiol Scand 1996, 40, 59-74); the guidelines were later revised and updated following the second consensus conference in Stockholm in 2005 (Fuchs-Buder et al., Acta Anaesthesiol Scand 2007, 51, 789-808). In view of new devices and further development of monitoring technologies that emerged since then, (e.g., electromyography, three-dimensional acceleromyography, kinemyography) as well as novel compounds (e.g., sugammadex) a review and update of these recommendations became necessary. The intent of these revised guidelines is to continue to help clinical researchers to conduct high-quality work and advance the field by enhancing the standards, consistency, and comparability of clinical studies. There is growing awareness of the importance of consensus-based reporting standards in clinical trials and observational studies. Such global initiatives are necessary in order to minimize heterogeneous and inadequate data reporting and to improve clarity and comparability between different studies and study cohorts. Variations in definitions of endpoints or outcome variables can introduce confusion and difficulties in interpretation of data, but more importantly, it may preclude building of an adequate body of evidence to achieve reliable conclusions and recommendations. Clinical research in neuromuscular pharmacology and physiology is no exception.

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation

BACKGROUND

Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice.

OBJECTIVES

To describe how PICU nurses are assessing and managing pain for children who require NMB.

METHODS

A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither.

RESULTS

A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent.

CONCLUSIONS

These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

Pressure injury incidence and impact on patients treated with prone positioning for COVID-19 ARDS

OBJECTIVE

To determine the incidence of pressure injuries (PIs) and their impact on clinical outcomes in patients treated with prone positioning for COVID-19 acute respiratory distress syndrome (ARDS).

METHOD

All patients with COVID-19 ARDS who were treated with prone positioning were categorised as cases and those who were not treated with prone positioning were categorised as controls. Demographics, clinical data and confounding variables affecting outcomes were recorded. Outcome variables of mortality and length of stay in intensive care units (ICUs) for both groups were recorded. Both groups' incidence of PIs were recorded and compared using statistical tests. Fisher's exact test was used for categorical variables, and Mann-Whitney U test was used for continuous variables.

RESULTS

The sample included 212 patients, treated with prone position (n=104) and without prone treatment (n=108). The incidence of PIs was n=75 (35.4%). PIs were significantly higher in patients in the prone position (n=51, 49%) compared with patients who were not (n=24, 22%); p=0.001. Patients in the prone position were found to have lower APACHE-2 scores, longer stays on the ventilator, ICU and in the hospital.

CONCLUSION

PIs are more prevalent in patients in the prone position and it adversely impacts clinical outcomes; it prolongs the length of stay on the ventilator, in the ICU and in the hospital.

Enteral Nutrition Safety and Outcomes of Patients with COVID-19 on Continuous Infusion of Neuromuscular Blockers: A Retrospective Study

Background

Intravenous infusions of neuromuscular blocking agents (NMBAs) and prone positioning are recommended for acute respiratory distress syndrome (ARDS) due to COVID-19. The safety of enteral nutrition (EN) during these treatments is unclear. This study assessed EN tolerance and safety during NMBA infusion in proned and nonproned patients with ARDS due to COVID-19.

Methods

This retrospective study evaluated patients who were admitted to a tertiary-care ICU between March and December 2020, had ARDS due to COVID-19, and received NMBA infusion. We assessed their EN data, gastrointestinal events, and clinical outcomes. The primary outcome was gastrointestinal intolerance, defined as a gastric residual volume (GRV) ≥500 ml or 200-500 ml with vomiting. We compared proned and nonproned patients.

Results

We studied 181 patients (mean age 61.2 ± 13.7 years, males 71.1%, and median body mass index 31.4 kg/m2). Most (63.5%) patients were proned, and 94.3% received EN in the first 48 hours of NMBA infusion at a median dose <10 kcal/kg/day. GRV was mostly below 100 ml. Gastrointestinal intolerance occurred in 6.1% of patients during NMBA infusion and 10.5% after NMBA discontinuation (similar rates in proned and nonproned patients). Patients who had gastrointestinal intolerance during NMBA infusion had a higher hospital mortality (90.9% versus 60.0%; p=0.05) and longer mechanical ventilation duration and ICU and hospital stays compared with those who did not.

Conclusion

In COVID-19 patients on NMBA infusion for ARDS, EN was provided early at low doses for most patients, and gastrointestinal intolerance was uncommon in proned and nonproned patients, occurred at a higher rate after discontinuing NMBAs and was associated with worse outcomes. Our study suggests that EN was tolerated and safe in this patient population.

The spine intra-abdominal pressure (SIAP) trial. A prospective, observational, single arm, monocenter study looking at the evolutions of the IAP prior, during and after spine surgery

BACKGROUND AND AIMS

Both anaesthesiologists and spine surgeons consider the intra-abdominal pressure (IAP) as an important peri-operative factor affected by patient positioning. We assessed the change in IAP caused by using a thoraco pelvic support (inflatable prone support, IPS) with the subject under general anesthesia. The IAP was measured before, during and immediately after surgery.

METHODS

The Spine Intra-Abdominal Pressure study (SIAP trial) is a prospective, single-arm, monocenter, observational study looking at changes in IAP prior, during and after spine surgery. The objective is to assess the change in IAP, measured via an indwelling urinary catheter, using the inflatable prone support (IPS) device during prone positioning of patients in spinal surgery.

RESULTS

Forty (40) subjects requiring elective lumbar spine surgery in prone position were enrolled after providing informed consent. The inflation of the IPS results in a significant decrease of IAP (from a median of 9.2 mmHg to 6.46 mmHg (p < 0.001)) in patients undergoing spine surgery in prone position. This decrease in IAP was maintained throughout the procedure despite the discontinuation of muscle relaxants. No serious adverse events or unexpected adverse events occurred.

CONCLUSION

The use of the thoraco-pelvic support IPS device was able to significantly lower the IAP during spine surgery.

Potential pharmacological confounders in the setting of death determined by neurologic criteria: a narrative review

Guidelines for the determination of death by neurologic criteria (DNC) require an absence of confounding factors if clinical examination alone is to be used. Drugs that depress the central nervous system suppress neurologic responses and spontaneous breathing and must be excluded or reversed prior to proceeding. If these confounding factors cannot be eliminated, ancillary testing is required. These drugs may be present after being administered as part of the treatment of critically ill patients. While measurement of serum drug concentrations can help guide the timing of assessments for DNC, they are not always available or feasible. In this article, we review sedative and opioid drugs that may confound DNC, along with pharmacokinetic factors that govern the duration of drug action. Pharmacokinetic parameters including a context-sensitive half-life of sedatives and opioids are highly variable in critically ill patients because of the multitude of clinical variables and conditions that can affect drug distribution and clearance. Patient-, disease-, and treatment-related factors that influence the distribution and clearance of these drugs are discussed including end organ function, age, obesity, hyperdynamic states, augmented renal clearance, fluid balance, hypothermia, and the role of prolonged drug infusions in critically ill patients. In these contexts, it is often difficult to predict how long after drug discontinuation the confounding effects will take to dissipate. We propose a conservative framework for evaluating when or if DNC can be determined by clinical criteria alone. When pharmacologic confounders cannot be reversed, or doing so is not feasible, ancillary testing to confirm the absence of brain blood flow should be obtained.

Enteral nutrition tolerance in patients receiving neuromuscular blockade

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.

The effect of shoulder muscle succinylcholine injection on the foreleg raising power: Sion's local paralysis

Objective

We examined the change in foreleg raising power after Sion's local paralysis (SLP) with succinylcholine in the shoulder muscle.

Methods

A randomized, double blind, placebo-controlled, porcine study was designed and performed at a research institution. Ten male Korean native pigs were randomized into an intervention group (n = 5) and a control group (n = 5). The injection points were in the middle of the left trapezius muscle and the middle of the left deltoid muscle. The control group received 2 ml normal saline (NS), 1 ml injected in each point. The intervention group received 0.4 mg/kg succinylcholine diluted to 2 ml in NS, and 1 ml was injected in each point. To represent the foreleg raising power, the height of the left forelegs from baseline (experiment table) was measured. We measured the foreleg height and oxygen saturation at -4, -2, 0, +2, +4, +6, +8, +10, +20, +30, and +60 min.

Results

After SLP, foreleg height immediately declined in the intervention group. It recovered slightly for a few minutes and declined from 4 to 8 min. In the control group, foreleg height was relatively similar throughout the study period. A repeated-measure analysis of variance revealed a significant group × time interaction (F_10,80 = 2.37, P = 0.017), a significant main effect for group (F_1,8 = 6.25, P = 0.037), and a significant main effect for time (F_10,80 = 4.41, P < 0.001). Post hoc analysis demonstrated that the intervention group showed significantly less foreleg raising power than the control group at 0, 4, 6, 8, 20, and 30 min (P < 0.05).

Conclusions

Compared with the control group, the foreleg raising power in the intervention group immediately decreased significantly and persisted for a period after SLP, without hypoxia, in a pig model.

Challenges in ARDS Definition, Management, and Identification of Effective Personalized Therapies

Over the last decade, the management of acute respiratory distress syndrome (ARDS) has made considerable progress both regarding supportive and pharmacologic therapies. Lung protective mechanical ventilation is the cornerstone of ARDS management. Current recommendations on mechanical ventilation in ARDS include the use of low tidal volume (VT) 4-6 mL/kg of predicted body weight, plateau pressure (PPLAT) < 30 cmH2O, and driving pressure (∆P) < 14 cmH2O. Moreover, positive end-expiratory pressure should be individualized. Recently, variables such as mechanical power and transpulmonary pressure seem promising for limiting ventilator-induced lung injury and optimizing ventilator settings. Rescue therapies such as recruitment maneuvers, vasodilators, prone positioning, extracorporeal membrane oxygenation, and extracorporeal carbon dioxide removal have been considered for patients with severe ARDS. Regarding pharmacotherapies, despite more than 50 years of research, no effective treatment has yet been found. However, the identification of ARDS sub-phenotypes has revealed that some pharmacologic therapies that have failed to provide benefits when considering all patients with ARDS can show beneficial effects when these patients were stratified into specific sub-populations; for example, those with hyperinflammation/hypoinflammation. The aim of this narrative review is to provide an overview on current advances in the management of ARDS from mechanical ventilation to pharmacological treatments, including personalized therapy.

Respiratory Monitoring During Mechanical Ventilation: The Present and the Future

The increased application of mechanical ventilation, the recognition of its harms and the interest in individualization raised the need for an effective monitoring. An increasing number of monitoring tools and modalities were introduced over the past 2 decades with growing insight into asynchrony, lung and chest wall mechanics, respiratory effort and drive. They should be used in a complementary rather than a standalone way. A sound strategy can guide a reduction in adverse effects like ventilator-induced lung injury, ventilator-induced diaphragm dysfunction, patient-ventilator asynchrony and helps early weaning from the ventilator. However, the diversity, complexity, lack of expertise, and associated cost make formulating the appropriate monitoring strategy a challenge for clinicians. Most often, a big amount of data is fed to the clinicians making interpretation difficult. Therefore, it is fundamental for intensivists to be aware of the principle, advantages, and limits of each tool. This analytic review includes a simplified narrative of the commonly used basic and advanced respiratory monitors along with their limits and future prospective.

Efficacy and Safety of Cisatracurium Compared to Vecuronium for Neuromuscular Blockade in Acute Respiratory Distress Syndrome

PURPOSE

Previous studies analyzing neuromuscular blocking agents (NMBAs) in acute respiratory distress syndrome (ARDS) have evaluated the benefit of cisatracurium with conflicting results, and data evaluating other NMBAs remains limited. The objective of this study was to compare the efficacy and safety of cisatracurium to vecuronium in ARDS.

MATERIALS AND METHODS

A single-center, retrospective, propensity matched review of patients who received cisatracurium or vecuronium continuous infusions between October 1, 2017 and June 30, 2020 for ARDS was conducted. The primary endpoint was duration of mechanical ventilation. Secondary endpoints included change in PaO₂/FiO₂ ratio at 48 h, intensive care unit (ICU) and hospital mortality, and ICU and hospital length of stay (LOS). Safety endpoints included newly developed myopathy, presence of bradycardia or hypotension, and newly developed barotrauma or volutrauma.

RESULTS

Twenty-nine patients were included in each group. There was no statistically significant difference in the primary endpoint of ventilator days between cisatracurium and vecuronium groups (mean 15.9 vs. 20.5 days respectively; p = .2). No statistically significant differences were found in secondary endpoints of ICU mortality (51.7% vs. 51.7%) or length of stay (18.7 vs. 23.9 days, p = .19), hospital mortality (51.7% vs. 55.2%, p = .79) or length of stay (22 vs. 30.6 days, p = .08), or mean change in PaO₂/FiO₂ (29.8 vs. 36.6; p = .74). Statistically significant differences were not observed in safety endpoints of myopathy (37.9% vs. 37.9%), barotrauma or volutrauma (13.8% vs. 3.5%; p = .16), bradycardia (31% vs. 13.8%; p = .12), or hypotension (96.6% vs. 82.8%; p = .08).

CONCLUSIONS

No significant differences were seen in efficacy or safety endpoints between cisatracurium or vecuronium groups, suggesting that vecuronium may be a safe alternative agent for neuromuscular blockade in ARDS. Results of this analysis warrant confirmation in a larger, randomized study.

Molecular mechanisms of muscular and non-muscular actions of neuromuscular blocking agents in critical illness: a narrative review

Despite frequent use of neuromuscular blocking agents in critical illness, changes in neuromuscular transmission with critical illness are not well appreciated. Recent studies have provided greater insights into the molecular mechanisms for beneficial muscular effects and non-muscular anti-inflammatory properties of neuromuscular blocking agents. This narrative review summarises the normal structure and function of the neuromuscular junction and its transformation to a 'denervation-like' state in critical illness, the underlying cause of aberrant neuromuscular blocking agent pharmacology. We also address the important favourable and adverse consequences and molecular bases for these consequences during neuromuscular blocking agent use in critical illness. This review, therefore, provides an enhanced understanding of clinical therapeutic effects and novel pathways for the salutary and aberrant effects of neuromuscular blocking agents when used during acquired pathologic states of critical illness.

Neuromuscular blockade in mechanically ventilated pneumonia patients with moderate to severe hypoxemia: A multicenter retrospective study

BACKGROUND/PURPOSE

The benefit of neuromuscular blockades (NMBs) in critically ill patients receiving mechanical ventilation remains uncertain. Therefore, we aimed to investigate whether NMB use is associated with improved survival of mechanically ventilated pneumonia patients with moderate to severe hypoxemia.

METHODS

This retrospective multicenter study was conducted at five university-affiliated hospitals. Data of pneumonia patients aged 18 years and older who received mechanical ventilation between January 1, 2011, and December 31, 2020, were analyzed.

RESULTS

In a total of 1,130 patients, the mean patient age was 73.1 years (SD±12.6), and the overall mortality rate at 30 d was 29.5% (n = 333). NMB users had a higher 30 d mortality rate than NMB nonusers (33.9% vs. 26.8%, P = 0.014). After PS matching, the 30 d mortality rate was not significantly different between NMB users and nonusers (33.4% vs. 27.8%, p = 0.089). However, 90 d mortality rate was significantly increased in NMB users (39.7% vs. 31.9%, p = 0.021). Univariable Cox proportional hazard regression analyses showed that NMB use ≥ 3 d was significant risk factor for the 90 d mortality than those with < 3 d use (90 d mortality HR 1.39 [95% CI: 1.01-1.91], P = 0.045).

CONCLUSIONS

NMB use was not associated with lower 30 d mortality among mechanically ventilated pneumonia patients with moderate to severe hypoxemia. Rather, NMB users had higher 90 d mortality, furthermore, and NMB use ≥ 3 d was associated with a higher risk of long-term mortality compared to NMB use < 3 d. Therefore, care should be taken to avoid extended use of NMB in critically ill pneumonia patients during mechanical ventilation.

Effect of Paralytic Agents on Post-Intubation Sedation in the Emergency Department

Purpose: This study aimed to evaluate the frequency at which postintubation sedation is administered following use of long-acting paralytic agents compared to short-acting paralytic agents during rapid sequence intubation performed in the emergency department. Methods: This retrospective, single-center study of intubated patients in the emergency department analyzed the difference in time to administration of additional sedation following use of a short-acting paralytic (succinylcholine) compared to use of a long-acting paralytic (rocuronium or vecuronium). A total of 387 patients were available for analysis. The primary outcome was additional sedation given within 15 minutes following administration of a paralytic agent. The secondary outcome sought to evaluate the incidence of hyperkalemia due to paralytic agents by comparing potassium level before and after paralytic administration. Results: 46.9% of patients who received a short-acting paralytic agent received additional sedation within 15 minutes, compared to 40.9% of patients who received a long-acting paralytic agent. The Chi-square analysis comparing the short and long-acting paralytic groups showed no statistically significant difference (χ² [1, N = 387] = 1.24, P = .266) in the frequency of additional sedation administered. Excluding patients who did not receive any additional sedation, the mean time from paralytic administration to additional sedation in all patients was 20.03 ± 18 minutes. No statistically significant difference was detected between groups regarding changes in potassium level. Conclusion: The use of long-acting paralytic agents was not associated with increased time to administration of sedation compared to shortacting paralytic agents. There is an opportunity to reduce the time to sedation administration for intubated patients receiving both short- and long-acting paralytic agents.

Physicians' attitudes and perceptions of neuromuscular blocker infusions in ARDS

PURPOSE

The perceptions and practices of ICU physicians regarding initiating neuromuscular blocker infusions (NMBI) in acute respiratory distress syndrome (ARDS) may not be evidence-based amidst the surge of severe ARDS during the SARS-CoV-2 pandemic and new practice guidelines. We identified ICU physicians' perspectives and practices regarding NMBI use in adults with moderate-severe ARDS.

MATERIALS AND METHODS

After extensive development and testing, an electronic survey was distributed to 342 ICU physicians from three geographically-diverse U.S. health systems(n = 12 hospitals).

RESULTS

The 173/342 (50.5%) respondents (75% medical) somewhat/strongly agreed a NMBI should be reserved until: after a trial of deep sedation (142, 82%) or proning (59, 34%) and be dose-titrated based on train-of-four monitoring (107, 62%). Of 14 potential NMBI risks, 2 were frequently reported to be of high/very high concern: prolonged muscle weakness with steroid use (135, 79%) and paralysis awareness due to inadequate sedation (114, 67%). Absence of dyssychrony (93, 56%) and use ≥48 h (87, 53%) were preferred NMBI stopping criteria. COVID-19 + ARDS patients were twice as likely to receive a NMBI (56 ± 37 vs. 28 ± 19%, p < 0.01).

CONCLUSIONS

Most intensivists agreed NMBI in ARDS should be reserved until after a deep sedation trial. Stopping criteria remain poorly defined. Unique considerations exist regarding the role of paralysis in COVID-19+ ARDS.

Neuromuscular Blockade in the Pre- and COVID-19 ARDS Patients

Acute respiratory distress syndrome (ARDS) accounts for a quarter of mechanically ventilated patients, while during the pandemic, it overwhelmed the capacity of intensive care units (ICUs). Lung protective ventilation (low tidal volume, positive-end expiratory pressure titrated to lung mechanics and oxygenation, permissive hypercapnia) is a non-pharmacological approach that is the gold standard of management. Among the pharmacological treatments, the use of neuromuscular blocking agents (NMBAs), although extensively studied, has not yet been well clarified. The rationale is to minimize the risk for lung damage progression, in the already-injured pulmonary parenchyma. By abolishing rigorous spontaneous efforts, NMBAs may decrease the generation of high transpulmonary pressures that could aggravate patients’ self-inflicted lung injury. Moreover, NMBAs can harmonize the patient–ventilator interaction. Recent randomized controlled trials reported contradictory results and changed the clinical practice in a bidirectional way. NMBAs have not been documented to improve long-term survival; thus, the current guidance suggests their use only in patients in whom a lung protective ventilation protocol cannot be applied, due to asynchrony or increased respiratory efforts. In the present review, we discuss the published data and additionally the clinical practice in the “war” conditions of the COVID-19 pandemic, concerning NMBA use in the management of patients with ARDS.

Neuromuscular blocking agents in the intensive care unit

Neuromuscular blocking agents (NMBA) are a controversial therapeutic option in the approach to the critically ill patient. They are not innocuous, and the available evidence does not support their routine use in the intensive care unit. If necessary, monitoring protocols should be established to avoid residual relaxation, adverse effects, and associated complications. This narrative review discusses the current indications for the use of NMBA and the different tools for monitoring blockade in the intensive care unit. However, expanding the use of NMBA in critical settings merits the development of prospective studies.

Second- and Third-Tier Therapies for Severe Traumatic Brain Injury

Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.

Evaluating the Medication Regimen Complexity Score as a Predictor of Clinical Outcomes in the Critically Ill

Background: Medication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The objective of this study was to examine the relationship between the scores of different MRC tools and the clinical outcomes. Methods: We conducted a retrospective cohort study at Roger William Medical Center, Providence, Rhode Island, which included 317 adult patients admitted to the intensive care unit (ICU) between 1 February 2020 and 30 August 2020. MRC was assessed using the MRC Index (MRCI) and MRC for the Intensive Care Unit (MRC-ICU). A multivariable logistic regression model was used to identify associations among MRC scores, clinical outcomes, and a logistic classifier to predict clinical outcomes. Results: Higher MRC scores were associated with increased mortality, a longer ICU length of stay (LOS), and the need for mechanical ventilation (MV). MRC-ICU scores at 24 h were significantly (p < 0.001) associated with increased ICU mortality, LOS, and MV, with ORs of 1.12 (95% CI: 1.06−1.19), 1.17 (1.1−1.24), and 1.21 (1.14−1.29), respectively. Mortality prediction was similar using both scoring tools (AUC: 0.88 [0.75−0.97] vs. 0.88 [0.76−0.97]. The model with 15 medication classes outperformed others in predicting the ICU LOS and the need for MV with AUCs of 0.82 (0.71−0.93) and 0.87 (0.77−0.96), respectively. Conclusion: Our results demonstrated that both MRC scores were associated with poorer clinical outcomes. The incorporation of MRC scores in real-time therapeutic decision making can aid clinicians to prescribe safer alternatives.