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

The COVID-19 Critical Care Consortium

doi:10.1186/s13054-022-03983-5

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

The COVID-19 Critical Care Consortium

Department of Pediatrics

Queensland Health
University of Queensland
August Pi i Sunyer Biomedical Research Institute
Queensland University of Technology
UnitingCare Hospitals
The Wesley Research Institute
COVID-19 Critical Care Consortium
Heart and Vascular Institute
CE170100009)
University of Galway
University of Toronto
University of Cape Town
Toronto General Hospital
IRCCS Fondazione Ca'Granda – Ospedale Maggiore Policlinico - Milano
University of Michigan, Ann Arbor
New York Presbyterian Hospital
Monash University
Alfred Health
Ospedale San Paolo
University of Milan
King Faisal Specialist Hospital and Research Centre
Universidad Nacional de Mar del Plata
Nippon Medical School
Universidad de Buenos Aires
National Cardiovascular Center Harapan Kita
University of Oxford
University of British Columbia
BC Children's Hospital Research Institute
University College Dublin
Alfred I. duPont Hospital for Children
University of Genoa
University of Genova
Hospital Clínic i Universitari
The University of Hong Kong
Al-Adan Hospital
Allegheny General Hospital
Avera Health
Barmherzige Bruder Regansburg
Baylor Scott & White Health
Baylor Health Care System

Research output: Contribution to journal › Article › peer-review

11 Scopus citations

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.

Original language	English
Article number	141
Journal	Critical Care
Volume	26
Issue number	1
DOIs	https://doi.org/10.1186/s13054-022-03983-5
State	Published - 1 Dec 2022

Bibliographical note

Publisher Copyright:
© 2022, The Author(s).

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

Keywords

COVID-19
Intensive care unit
Mechanical ventilation
Neuromuscular blocking agent
SARS-CoV-2

Access to Document

10.1186/s13054-022-03983-5

Cite this

@article{038ce3d78e65443f96ade951138d2c70,

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

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.",

keywords = "COVID-19, Intensive care unit, Mechanical ventilation, Neuromuscular blocking agent, SARS-CoV-2",

author = "\{The COVID-19 Critical Care Consortium\} and \{Li Bassi\}, Gianluigi and Kristen Gibbons and Suen, \{Jacky Y.\} and Dalton, \{Heidi J.\} and Nicole White and Amanda Corley and Sally Shrapnel and Samuel Hinton and Simon Forsyth and Laffey, \{John G.\} and Eddy Fan and Fanning, \{Jonathon P.\} and Mauro Panigada and Robert Bartlett and Daniel Brodie and Aidan Burrell and Davide Chiumello and Alyaa Elhazmi and Mariano Esperatti and Giacomo Grasselli and Carol Hodgson and Shingo Ichiba and Carlos Luna and Eva Marwali and Laura Merson and Srinivas Murthy and Alistair Nichol and Mark Ogino and Paolo Pelosi and Antoni Torres and Ng, \{Pauline Yeung\} and Fraser, \{John F.\} and Tala Al-Dabbous and Huda Alfoudri and Mohammed Shamsah and Subbarao Elapavaluru and Ashley Berg and Christina Horn and Yunis Mayasi and Stephan Schroll and Dan Meyer and Jorge Velazco and Ludmyla Ploskanych and Wanda Fikes and Rohini Bagewadi and Marvin Dao and Haley White and Dan Meyer and Ashley Ehlers and Kang, \{Hyun Mi\}",

note = "Publisher Copyright: {\textcopyright} 2022, The Author(s).",

year = "2022",

month = dec,

day = "1",

doi = "10.1186/s13054-022-03983-5",

language = "English",

volume = "26",

journal = "Critical Care",

issn = "1364-8535",

publisher = "BioMed Central Ltd.",

number = "1",

}

TY - JOUR

T1 - Early short course of neuromuscular blocking agents in patients with COVID-19 ARDS

T2 - a propensity score analysis

AU - The COVID-19 Critical Care Consortium

AU - Li Bassi, Gianluigi

AU - Gibbons, Kristen

AU - Suen, Jacky Y.

AU - Dalton, Heidi J.

AU - White, Nicole

AU - Corley, Amanda

AU - Shrapnel, Sally

AU - Hinton, Samuel

AU - Forsyth, Simon

AU - Laffey, John G.

AU - Fan, Eddy

AU - Fanning, Jonathon P.

AU - Panigada, Mauro

AU - Bartlett, Robert

AU - Brodie, Daniel

AU - Burrell, Aidan

AU - Chiumello, Davide

AU - Elhazmi, Alyaa

AU - Esperatti, Mariano

AU - Grasselli, Giacomo

AU - Hodgson, Carol

AU - Ichiba, Shingo

AU - Luna, Carlos

AU - Marwali, Eva

AU - Merson, Laura

AU - Murthy, Srinivas

AU - Nichol, Alistair

AU - Ogino, Mark

AU - Pelosi, Paolo

AU - Torres, Antoni

AU - Ng, Pauline Yeung

AU - Fraser, John F.

AU - Al-Dabbous, Tala

AU - Alfoudri, Huda

AU - Shamsah, Mohammed

AU - Elapavaluru, Subbarao

AU - Berg, Ashley

AU - Horn, Christina

AU - Mayasi, Yunis

AU - Schroll, Stephan

AU - Meyer, Dan

AU - Velazco, Jorge

AU - Ploskanych, Ludmyla

AU - Fikes, Wanda

AU - Bagewadi, Rohini

AU - Dao, Marvin

AU - White, Haley

AU - Meyer, Dan

AU - Ehlers, Ashley

AU - Kang, Hyun Mi

PY - 2022/12/1

Y1 - 2022/12/1

N2 - 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.

AB - 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.

KW - COVID-19

KW - Intensive care unit

KW - Mechanical ventilation

KW - Neuromuscular blocking agent

KW - SARS-CoV-2

UR - https://www.scopus.com/pages/publications/85130163070

U2 - 10.1186/s13054-022-03983-5

DO - 10.1186/s13054-022-03983-5

M3 - Article

C2 - 35581612

AN - SCOPUS:85130163070

SN - 1364-8535

VL - 26

JO - Critical Care

JF - Critical Care

IS - 1

M1 - 141

ER -

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

Abstract

Bibliographical note

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Keywords

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