In this episode, I’ll discuss 5 steps an ED or ICU pharmacist can take to prevent awareness with paralysis.
Awareness with paralysis occurs when a patient receives a paralytic for rapid sequence intubation but does not receive ongoing sedation before the induction agent wears off.
In the context of OR patients, awareness with paralysis occurs about 0.1% of the time, while two recent studies put the prevalence in ED and ICU patients at 2.6 and 3.4%. These studies were discussed in episode 578 and episode 580.
What is likely happening in the ED and ICU setting is the induction agents from rapid sequence intubation is wearing off before the paralytic, and post-intubation sedation is not being applied fast enough.
A previous study did demonstrate that the presence of a pharmacist can significantly decrease the time to sedation in patients who have just undergone rapid sequence intubation.
Here are the 5 steps that I take to ensure awareness with paralysis does not occur after rapid sequence intubation:
1. Enter the patient room with sedative and analgesia boluses prior to the procedure that are in addition to whatever is being used for induction
2. Note the exact time that induction medications were given
3. After intubation, state the time since induction to the team and give a recommendation for sedation
4. Establish a plan for ongoing sedation with the provider.
5. Provide infusions to the nurse in the most ready-to-use form possible including obtaining the
smart pump, IV tubing, spiking the bag and priming the tubing, and labeling the lines.
Members of my Hospital Pharmacy Academy have access to practical trainings on preventing awareness with paralysis and Airway Pharmacology where I cover paralytic and sedative choices for the 6 different types of airway scenarios, as well as how to anticipate and deal with complications related to intubation. The Hospital Pharmacy Academy is my online membership site that teaches pharmacists practical critical care and hospital pharmacy skills you can apply at the bedside so that you can become confident in your ability to save lives and improve patient outcomes. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.