(1250) Roc and Roll: Inadequate Reversal Prior to Extubation

Introduction: Neuromuscular blocking (NMB) drugs like rocuronium are commonly used to facilitate intubation and other procedures in the intensive care unit (ICU). After administration, drug offset is markedly variable between patients, with some individuals having residual paralysis for well over 12-hours. Unfortunately, bedside clinical assessments and qualitative monitoring fail to capture residual paralysis at the level of the airway. This can result in adverse respiratory outcomes, such as pneumonia. Accordingly, governing body guidelines recommend quantitative monitoring to ensure resolution of NMB and to guide drug reversal.

In the ICU, data exists suggesting that quantitative monitoring of NMB is infrequently used, even when reversal agents are not administered. An improved understanding of practice patterns is required.

Methods: A 10 question cross-sectional survey was administered. Questionnaires were sent to all 436 United States fellowship program directors in critical care anesthesiology, pulmonary & critical care medicine and surgical critical care. No duplicate ICU entries were allowed.

Results: Of 46 total respondents (46/436, 11%), 15% (7/46) said that reversal agents are nearly always administered and 17% (8/46) said reversal is rarely/never administered in their practice. When extubation is planned and paralysis has been administered but not reversed, 33% (14/43) of respondents always / almost always monitor for residual NMB; 42% [18/43] rarely/never monitor. Time since last exposure to rocuronium was used 22% (10/46) of the time to determine if reversal of paralysis was required. If reversal agents are administered, 24% (10/42) then monitor for residual NMB prior to extubating; 52% (22/42) rarely/never monitor.

Practices vary between ICUs, with cardiothoracic ICUs always or nearly always reversing paralysis 25% of the time (2/8), followed by surgical (12.5%, 3/24) then medical ICUs (9%, 1/11). Reversal is rarely/never administered most often in the medical ICU (36%, 4/11), versus the surgical ICU (12.5%, 3/24) and cardiothoracic ICU (12.5%, 1/8).

Conclusions: Current ICU clinical practice does not follow clinical practice guidelines. This varies based on ICU subtype. Patients are at risk of residual NMB and adverse respiratory outcomes.