Comparison of Train-of-Four Versus No Train-of-Four Monitoring of Neuromuscular Blockade on Drug Consumption for Acute Respiratory Distress Syndrome

Abstract

Background:

There is limited data regarding the use of clinical assessment alone for neuromuscular blockade (NMB) titrations in the setting of acute respiratory distress syndrome (ARDS).

Objective:

To compare the amount of cisatracurium (CIS) consumed when utilizing train-of-four (TOF)-guided NMB titrations or clinical assessment alone without TOF for continuous infusion (CI) administration.

Methods:

A retrospective analysis was performed evaluating TOF-guided titrations compared with clinical assessment alone (non-TOF) for CI NMB with CIS. Individuals within the TOF group were assessed from January 2013 to December 2018 while those within the clinical assessment alone group were assessed from January 2021 to December 2024. Patients were excluded if they were less than 18 years old, had documentation of COVID-19 infection, were receiving extracorporeal membrane oxygenation, or had NMB initiated at an outside hospital. The primary objective was assessing drug utilization between groups.

Results:

A total of 1047 and 553 individuals were screened resulting in 99 and 65 included for analysis in the TOF and non-TOF groups, respectively. The median cumulative CIS dose was 665 (472, 927) mg in the TOF group and 536 (400, 699) mg in the clinical assessment alone group, P = 0.011. The median infusion rate was 32% higher in the TOF group: 2.5 (1.8, 3.6) versus 1.9 (1.8, 2.4) µg/kg/min, P < 0.001, despite similar starting rates. Median drug costs were also significantly reduced when comparing the TOF group with the non-TOF group: $178 (126, 247) versus $143 (107, 187), P = 0.011.

Conclusion and Relevance:

This study assesses drug utilization when comparing TOF-guided NMB titration with clinical assessment alone in the modern ARDS era. Utilization of clinical assessment alone without TOF monitoring for CI CIS resulted in significantly reduced drug utilization and costs. Further studies are needed to assess the impact of clinical assessment alone on improvement of oxygenation.