Use of neuromuscular blocking agents in mechanically ventilated patients with COVID-19: A propensity score analysis

Abstract

Background: Neuromuscular blocking agents (NMBA) have been previously used in patients with acute respiratory distress syndrome (ARDS).

Objective: To investigate if NMBA are useful in COVID-19 patients who require invasive mechanical ventilation (IMV).

Methods: We investigated use of NMBA in COVID-19 patients on IMV from February 1 to November 24, 2020, in 147 hospitals across 6 continents, comprising the COVID-19 Critical Care Consortium. We performed propensity score (PS) matched Cox proportional hazards analysis to appraise the impact of NMBA use for ≥2 days, continuously or discontinuously (treatment), vs. no use of NMBA or only upon commencement of IMV (control) on 28-day intensive care unit (ICU) mortality.

Results: 1548 (72%) patients received any NMBA therapy; 1165 (54%) of patients were stratified in the treatment group, 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 (N=1548). Upon commencement of IMV, patients who received NMBA therapy had a lower mean (±SD) PaO2/FiO2 (139±75 vs 157±93; P<0.001). After PS matching, Cox proportional hazard model demonstrated that NMBA therapy was significantly associated with 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.

Conclusions: Use of NMBA is common in COVID-19 patients on IMV and associated with a 2.2-fold increase in risk of 28-day mortality. Until further randomised evidence is available, NMBA should be applied cautiously in routine clinical practice.