J Clin Transl Res . Risk of post-intubation cardiac arrest with the use of high-dose rocuronium in COVID-19 patients with acute respiratory distress syndrome: A retrospective cohort study

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J Clin Transl Res


. 2021 Oct 30;7(6):717-722.
eCollection 2021 Dec 28.
Risk of post-intubation cardiac arrest with the use of high-dose rocuronium in COVID-19 patients with acute respiratory distress syndrome: A retrospective cohort study


Natalie Kandinata ¹ , Roshan Acharya ¹ , Aakash Patel ¹ , Aalok Parekh ¹ , Jessica Santana ² , Aaron Darden ³ , Yub Raj Sedhai ⁴ , Smita Kafle ⁵ , Usman Younus ⁶



Affiliations

• PMID: 34901517
• PMCID: PMC8654367

Abstract

Background: Post-intubation cardiac arrest (PICA) is an uncommon complication of intubation, but numbers have risen to over 1.5 times the usual number since the coronavirus disease 2019 (COVID-19) pandemic. Due to expert recommendations, high-dose rocuronium (HDR) has become a commonly used pre-intubation neuromuscular blocking agent.
Aim: We conducted this retrospective case-control observational study with the hypothesis that high-dose rocuronium was not associated with higher incidence of PICA.
Methods: We included 93 patients who were intubated using the rapid sequence intubation (RSI) technique with rocuronium for acute respiratory distress syndrome (ARDS) due to confirmed COVID-19 pneumonia, admitted from March 2020 to February 2021 to a tertiary care hospital in North Carolina, USA. The patients were grouped based on high (1.5 mg/kg of ideal body weight and above) versus low (<1.5 mg/kg of ideal body weight) dose rocuronium used for RSI. The differences of the various outcomes between the groups were analyzed.
Results: The baseline demographics were similar in both groups except for higher body mass index in high-dose group 39 versus 32 (kg/m²), p = 0.009. There was a total of six PICA events (6.45%). The HDR group had 8.0% of PICA versus 4.7% in the low-dose group. In-hospital mortality was 60.0% in the HDR group versus 72.1% in the low-dose group.
Conclusion: The incidence of PICA in COVID-19 patients with ARDS who were intubated using the RSI technique was higher than in the pre-COVID-19 era.
Relevance for patients: The use of high-dose paralytics during invasive ventilation with RSI and their consequences should be explored with the help of large-scale studies. The rate of PICA is still very low, and perhaps, the use of HDR is safe, as suggested by the expert panel.

Keywords: COVID-19; acute respiratory distress syndrome; etomidate; peri-intubation cardiac arrest; post-intubation cardiac arrest; rapid sequence intubation; rocuronium.