OasisLMS

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Julie Dibridge

Introduction/Hypothesis: In patients with moderate to severe Acute Respiratory Distress Syndrome (ARDS), guidelines recommend the use of neuromuscular blocking agents (NMBA) but do not make recommendations for a dosing scheme. The optimal strategy to minimize drug exposure, while not compromising efficacy is yet to be clearly established in the literature. Currently, our institution utilizes three different dosing regimens: fixed dose (FD), titration based on train-of-four (TOF), and a ventilator synchrony (VS) protocol. The objective of this study was to determine the effect of dosing strategy on drug consumption and oxygenation in ARDS patients.

Methods: This was a retrospective review of patients with ARDS who received continuous cisatracurium infusion for at least 36 hours between January 2013 and December 2018. Included patients were categorized into one of three dosing strategies (FD, TOF, or VS), as determined by ordered titration parameters. Data were collected from NMBA initiation to the end of paralysis or 48 hours, which ever occurred sooner. The drug utilization outcome was defined as total cisatracurium drug consumption and cost within 48 hours. The efficacy outcome was defined as change in PaO2:FiO2 (PF) and number of spontaneous breaths over the ventilator from baseline to 12, 24, 36 and 48 hours. Categorical data was compared using Chi squared or Fishers exact test as appropriate. Continuous data was compared using Kruskal-Wallis test and Mann-Whitney U test in pairwise fashion. Change in PF ratios were analyzed using T-test of equivalence in a pairwise fashion.

Results: A total of 1078 patients were screened, and 223 patients (FD = 22; TOF = 110; VS = 91) were included. The median infusion rate (mcg/kg/min) was higher in the FD and TOF arm than the VS group: FD 7.5 [IQR 6.7-8.9, p<0.00001], TOF 2.5 [IQR 2-3.5, p<0.0001], VS 1.67 [IQR 1.35-2]. Cost of therapy was higher in the FD and TOF arm than the VS group: FD $4,140, p<0.00001, TOF $1,615, p<0.00001, VS $911. No difference was observed in change in PF ratios or spontaneous breaths over the ventilator.

Conclusions: Without impacting efficacy of gas exchange or ventilator synchrony, the VS protocol required significantly less drug with lower total costs than either TOF or FD protocols. Further prospective research is needed to confirm these results.