(968) Sedation and Analgesia During Continuous Neuromuscular Blockade

Introduction: Neuromuscular blocking agents (NMBAs) are used to medically induce paralysis through the blockade of neuronal impulses within the neuromuscular junction. Sedation and analgesia is recommended when patients are on a continuous NMBA, with a goal of deep sedation. However, there is minimal literature surrounding optimal dosing of sedative and analgesic agents in this circumstance. Current guidelines suggest that a bispectral index monitor can be used to assess level of sedation while receiving a NMBA, however this is supported by a limited number of outcome-based studies. The purpose of this study was to evaluate sedation and analgesia practices in patients receiving a continuous NMBA.

Methods: This retrospective observational cohort study evaluated patients greater than 18 years of age receiving continuous neuromuscular blockade for greater than 24 hours between November 1, 2020 and October 21, 2021. The primary endpoint was achievement of goal sedation score within the first six hours of NMBA initiation. Secondary endpoints included achievement of goal sedation score prior to NMBA initiation and 24 hours after initiation, discontinuation or selection of alternative agent due to adverse effects, and dose of sedative and analgesic agents at NMBA therapy initiation and achievement of goal sedation score.

Results: One hundred patients were included in the study. All patients received cisatracurium as their NMBA with a median duration of 96 hours. The most common indication for NMBA therapy was acute respiratory distress syndrome (75%) followed by ventilator dyssynchrony (23%). The primary outcome was achieved in 82% of patients. Goal sedation score was achieved in 66% prior to NMBA initiation and 90% at 24 hours after NMBA initiation. Adverse effects resulting in change or discontinuation of sedation or analgesic agents occurred in 13% of patients. The median dose of fentanyl, hydromorphone, propofol, and midazolam was increased at goal sedation attainment compared to initiation of the NMBA.

Conclusions: While this was a small study, these results may be used to guide empiric dosing of sedation and analgesic agents, allowing for early goal sedation attainment in patients on continuous NMBAs.