Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America.
Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
J Crit Care. 2022 Dec;72:154165. doi: 10.1016/j.jcrc.2022.154165. Epub 2022 Oct 6.
The perceptions and practices of ICU physicians regarding initiating neuromuscular blocker infusions (NMBI) in acute respiratory distress syndrome (ARDS) may not be evidence-based amidst the surge of severe ARDS during the SARS-CoV-2 pandemic and new practice guidelines. We identified ICU physicians' perspectives and practices regarding NMBI use in adults with moderate-severe ARDS.
After extensive development and testing, an electronic survey was distributed to 342 ICU physicians from three geographically-diverse U.S. health systems(n = 12 hospitals).
The 173/342 (50.5%) respondents (75% medical) somewhat/strongly agreed a NMBI should be reserved until: after a trial of deep sedation (142, 82%) or proning (59, 34%) and be dose-titrated based on train-of-four monitoring (107, 62%). Of 14 potential NMBI risks, 2 were frequently reported to be of high/very high concern: prolonged muscle weakness with steroid use (135, 79%) and paralysis awareness due to inadequate sedation (114, 67%). Absence of dyssychrony (93, 56%) and use ≥48 h (87, 53%) were preferred NMBI stopping criteria. COVID-19 + ARDS patients were twice as likely to receive a NMBI (56 ± 37 vs. 28 ± 19%, p < 0.01).
Most intensivists agreed NMBI in ARDS should be reserved until after a deep sedation trial. Stopping criteria remain poorly defined. Unique considerations exist regarding the role of paralysis in COVID-19+ ARDS.
在 SARS-CoV-2 大流行和新的实践指南期间，严重急性呼吸窘迫综合征（ARDS）患者激增，重症加强护理病房（ICU）医生对启动神经肌肉阻滞剂输注（NMBI）的看法和做法可能不符合循证医学。我们确定了 ICU 医生对中度至重度 ARDS 成人使用 NMBI 的看法和做法。
在经过广泛的开发和测试后，向来自三个地理位置不同的美国医疗系统的 342 名 ICU 医生（n = 12 家医院）分发了电子调查。
173/342（50.5%）的受访者（75%为医生）有些/强烈同意，NMBI 应保留至：深度镇静试验后（142 人，82%）或俯卧位后（59 人，34%），并根据四成监测滴定剂量（107 人，62%）。在 14 种潜在的 NMBI 风险中，有 2 种被频繁报告为高度/非常高关注：类固醇使用导致的肌无力延长（135 人，79%）和因镇静不足导致的瘫痪意识（114 人，67%）。缺乏不同步（93 人，56%）和使用时间≥48 小时（87 人，53%）是首选的 NMBI 停药标准。COVID-19+ARDS 患者接受 NMBI 的可能性是 COVID-19-ARDS 患者的两倍（56±37%比 28±19%，p<0.01）。
大多数重症监护医生同意，ARDS 中的 NMBI 应保留至深度镇静试验后。停药标准仍未明确定义。在 COVID-19+ARDS 中，瘫痪的作用存在独特的考虑因素。
