Use of Neuromuscular Blocking Agents in Mechanically Ventilated Patients with COVID-19: A Propensity Score Analysis

Abstract

Introduction. Controversy surrounding neuromuscular blocking agents (NMBA) use in patients with early acute respiratory distress syndrome (ARDS) has persisted throughout the years. However, whether NMBAs are useful in Coronavrus Disease 2019 (COVID-19) patients requiring invasive mechanical ventilation (IMV) is unknown. Objectives. To appraise the effect of NMBAs in COVID-19 mechanically ventilated patients on 28-day intensive care unit (ICU) mortality. Methods. We investigated NMBA use in COVID-19 patients on IMV from February 1 to November 24, 2020, in 147 hospitals across six continents, all part of the COVID-19 Critical Care Consortium. We performed univariate analyses to compare patients with or without NMBA treatment. A propensity score matched Cox proportional hazards analysis, incorporating time-varying NMBA treatment, was carried out to appraise the effect of NMBA on 28-day intensive care unit (ICU) mortality. Results. 1019 out of 1885 (54%) patients received NMBA therapy, with a median (IQR) time from ICU admission to commencement of NMBA therapy of 0 (0-2) days. The median (IQR) duration of NMBA therapy was 3 (2-6) days. Upon commencement of IMV, patients who received NMBA therapy had a lower mean (± SD) PaO2/FiO2 (143 ± 76 vs 160 ± 93; P = 0.002). After propensity score matching, Cox proportional hazard modelling demonstrated that NMBA therapy was associated with significantly higher 28-day ICU mortality (adjusted HR = 2.20, 95% CI 1.67, 2.89, P < 0.001). Sensitivity analyses testing various NMBA therapeutic regimens confirmed similar associations with mortality. Conclusion. Early use of NMBA is common in COVID-19 patients on IMV and associated with a 2.2-fold increase 28-day mortality risk. In the absence of definitive data from clinical trials, our data suggest that NMBA should be applied cautiously in this setting.