Early short course of neuromuscular blocking agents in patients with COVID-19 ARDS: a propensity score analysis
Gianluigi Li Bassi, Kristen Gibbons, Jacky Y. Suen, Heidi J. Dalton, Nicole White, Amanda Corley, Sally Shrapnel, Samuel Hinton, Simon Forsyth, John G. Laffey, Eddy Fan, Jonathon P. Fanning, Mauro Panigada, Robert H. Bartlett, Daniel Brodie, Aidan Burrell, Davide Chiumello, Alyaa Elhazmi, Mariano Esperatti, Giacomo Grasselli, Carol Hodgson, Shingo Ichiba, Carlos Luna, Eva Miranda Marwali, Laura Merson, Srinivas Murthy, Alistair Nichol, Mark Ogino, Paolo Pelosi, Antoní Torres, Pauline Yeung Ng, John F. Fraser, Tala Al-dabbous, Huda Alfoudri, Mohammed Shamsah, Subbarao Elapavaluru, Ashley Berg, Christina Horn, Yunis Mayasi, Stephan Schroll, Dan M. Meyer, Jorge Velazco, Ludmyla Ploskanych, Wanda Fikes, Rohini Bagewadi, Marvin Dao, Haley White, Dan M. Meyer, Ashley Ehlers, Maysoon Shalabi-McGuire, Trent Witt, Lorenzo Grazioli, Ferdinando Luca Lorini, E. Wilson Grandin, Jose I. Nunez, Tiago Reyes, Diarmuid O’Briain, Stephanie Hunter, Mahesh Ramanan, Julia Affleck, Hemanth Hurkadli Veerendra, Sumeet Rai, Josie Russell-Brown, Mary Nourse, Mark Joseph, Brook Mitchell, Martha M. Tenzer, Ryuzo Abe, Hwa Jin Cho, In Seok Jeong, Nadeem Rahman, Vivek Kakar, Nicolas Brozzi, Omar Mehkri, Sudhir Krishnan, Abhijit Duggal, Stuart Houltham, Jerónimo Graf, Roderigo Diaz, Roderigo Orrego, Camila Delgado, Joyce González, María Soledad Sánchez, Michaël Piagnerelli, Josefa Valenzuela Sarrazin, A. Prof. Gustavo Zabert, Lucio Espinosa, Paulo Delgado, Victoria Delgado, Diego Fernando Bautista Rincón, Angela Maria Marulanda Yanten, Melissa Bustamante Duque, Daniel Brodie, Alyaa Elhazmi, Abdullah Al-Hudaib, Maria Callahan, M Azhari Taufik, Elizabeth Yasmin Wardoyo, Margaretha Gunawan, Nurindah S. Trisnaningrum
Abstract
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.