299: Evaluation of Rocuronium in Critically Ill Patients During the COVID-19 Pandemic

Abstract

INTRODUCTION: Limited data exist to support the use of rocuronium continuous infusions in the intensive care unit (ICU). Due to a shortage of cisatracurium, our Pharmacy and Therapeutics committee approved the use of rocuronium as a therapeutic alternative. The objective of this study was to evaluate the dosing and monitoring of adult patients who received rocuronium for hypoxemic respiratory failure during the COVID-19 pandemic. METHODS: This was a prospective, single-center study from March 1, 2020 to May 31, 2020. We identified all adult patients admitted to any ICU who received rocuronium via continuous infusion. Patients were excluded if they received rocuronium for < 6 hours. Study subjects could have multiple paralysis infusions during the same admission. Each rocuronium infusion was separated by at least 24 hours. The main outcome of this study was the relationship between the hourly administration rate of rocuronium and TOF assessment by using Pearson correlation coefficient. Secondary outcomes of this study included median rocuronium dose at initiation, duration of infusion, and median rate of infusion. TOF results were classified as over-paralyzed (TOF = 0), wellparalyzed (TOF = 1-2), or under-paralyzed (TOF = 3-4). RESULTS: Seventy-one patients and 97 paralysis infusions were included. Fifty-nine patients (83%) were positive for SARS CoV-2. There was a negligible correlation between the dose of rocuronium and the TOF results (r = 0.04). Of the 97 paralysis infusions, the median dose at initiation was 3 [3-5] mcg/kg/min and duration of infusion was 45 [23.6-92.5] hours. The median rate of infusion was 4.3 [2.8-7.2] mcg/kg/ min. A total of 1775 TOFs were assessed, of which 46.2% were over-paralyzed, 35.7% well-paralyzed, and 18.1% under-paralyzed. CONCLUSIONS: We found no correlation between rocuronium dose and TOF assessments. The initial and maintenance infusion doses in our analysis were lower than what have been previously referenced. As TOF is unpredictable, patients initiated on continuous infusion rocuronium may be started at lower doses while being titrated to ventilator synchrony to avoid over-paralysis.