(1004) Use of Clinical Parameter vs Train-of-Four for Neuromuscular Blocking Agents in Patients With ARDS

Introduction: Various dosing titration strategies utilizing different monitoring parameters have been studied for paralytics in acute respiratory distress syndrome (ARDS) including train of four (TOF) and clinical parameters (CP), such as achieving ventilator synchrony to facilitate ventilator compliance (while also using TOF monitoring to ensure that the patient is not over paralyzed). Additionally, no studies have evaluated the use of continuous infusions of rocuronium in ARDS. The purpose of this study was to evaluate the clinical effects of titrating rocuronium to achieve a goal paralysis with TOF versus a CP in patients with ARDS.

Methods: This was a retrospective cohort study of adult patients with moderate-to-severe ARDS who received a rocuronium continuous infusion for at least 48 hours titrated to either TOF or a CP of “no spontaneous breathing”. The primary outcome was cumulative rocuronium drug consumption within the first 48 hours of paralytic infusion.

Results: Of the 114 patients included, 52 were in the TOF group and 62 were in the CP group. At baseline, more medical and COVID-19 positive patients were in the CP group. There was no difference found in the primary outcome of cumulative rocuronium drug consumption within the first 48 hours of paralytic initiation (23 mg/kg in TOF vs 23 mg/kg in CP p=0.42). Patients in the CP group had higher cumulative rocuronium drug consumption over the entire duration of paralytics (median 33.4mg/kg in TOF vs 41.5 mg/kg in CP, p=0.01) likely due to a higher duration of paralytic use (median 2.9 days in TOF vs 3.6 days in CP, p=0.017).

Conclusions: In the treatment of patients with moderate-to-severe ARDS, no difference was seen in the primary outcome of cumulative rocuronium drug consumption within the first 48 hours of paralytic initiation when comparing titration TOF to a CP. This differs from previous literature showing a reduction of paralytic usage in patients being monitored with a CP. This difference likely stems from a lack of TOF monitoring in the CP group as well as a lack of titrating the rocuronium to the lowest dose needed to achieve the CP. The results of this study show that extensive education and a robust CP titration protocol are likely essential in order to see a reduction in paralytic usage when titrating to a clinical parameter.