Neuromuscular blockade management in patients with COVID-19

Abstract

This narrative review evaluates the evidence for using neuromuscular blocking agents (NMBA) in patients being treated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While large prospective randomized-controlled trials (RCTs) are lacking at this point in time, smaller observational studies and case series are reviewed to ascertain the indications and utility of NMBAs. Additionally, large RCTs that address similar clinical scenarios are reviewed and the authors translate these findings to patients with COVID-19. Specifically, NMBAs can be helpful during endotracheal intubation to minimize the risk of patient coughing and possibly infecting healthcare personnel. NMBAs can also be used in patients to promote patient-ventilator synchrony while reducing the driving pressure needed with mechanical ventilation, particularly in patients with the severe clinical presentation (Type H phenotype). Prone positioning has also become a cornerstone in managing refractory hypoxemia in patients with SARS-CoV-2 acute respiratory distress syndrome (ARDS), and NMB can be useful in facilitating this maneuver. In the perioperative setting, deep levels of neuromuscular blockade can improve patient outcomes during laparoscopic operations and may theoretically reduce the risk of aerosolization as lower insufflation pressures may be utilized. Regardless of the indication, quantitative neuromuscular monitoring remains the only reliable method to confirm adequate recovery following cessation of neuromuscular blockade. Such monitors may serve a unique purpose in patients with COVID-19 as automation of measurements can reduce healthcare personnel -patient contact that would occur during periodic subjective evaluation with a peripheral nerve stimulator.

Characteristics of postintubation dysphagia in ICU patients in the context of the COVID-19 outbreak: A report of 920 cases from a Brazilian reference center

“…A large proportion of the severely affected patients with COVID-19 used medications such as neuromuscular blockers and corticosteroids due to severe respiratory alterations, need for mechanical ventilation, prone position and the inflammatory response to the disease [ 48 ]. The use of these drugs is known to be significantly associated with ICU acquired muscle weakness and neuropathies, and therefore can increase the risk of developing dysphagia [ 49 ].…”

Manifestações orais em pacientes com COVID-19 internados em Unidade de Terapia Intensiva

“…Já com relação às lesões traumáticas, pode-se estabelecer uma correlação com o uso de bloqueadores neuromusculares e maiores índices daquelas. A ampla escolha de bloqueadores neuromusculares para pacientes com COVID-19 objetiva-se em diminuir assincrônias respiratórias com relação à VMI, promover uma posição de pronação com menores índices de extubação acidental, evitar movimentos físicos e tosse durante procedimentos como aspiração endotraqueal e broncoscopias, dentre outras 20 . Em observância da última indicação citada, nós acreditamos que a falta de mobilidade proporcionada por esse fármaco corrobora para a diminuição de ocorrência desse tipo de lesão, que é causada, principalmente, por atos de mordedura, comumente verificados no setor estudado.…”

Neuromuscular blocking agents in the intensive care unit

“…2,32 Monitoring facial muscles can prove challenging because direct muscle stimulation easily occurs; however, the corrugator supercilii muscle reportedly responds to NMBA similarly to the diaphragm and laryngeal muscles, while the orbicularis oculi can respond similarly to the extremities. 33 Experts' consensuses discourage monitoring facial muscles because there is a more than five-fold higher risk of residual paralysis when monitoring is performed at the eye muscles than at the hand muscles. 33 Quantitative monitoring methods use devices that stimulate the peripheral nerve while also recording, quantifying, and numerically displaying the evoked responses patterns.…”