In this episode, I’ll discuss an article about awareness with paralysis among critically ill emergency department patients.
Rapid sequence intubation is a common procedure in the ED. After this procedure where a paralytic such as succinylcholine or rocuronium has been used along with a short-acting sedative such as propofol, ketamine, or etomidate, a definitive plan for ongoing sedation and analgesia must be made.
However, if ongoing sedation and analgesia is not implemented promptly, the possibility of awareness with paralysis exists. In this state, the patient is aware of their surroundings but cannot act or communicate their awareness. This could result in considerable long-term psychological trauma.
With the sometimes busy and chaotic environment of emergency departments, it is easy to envision a scenario where the provision of sedation is delayed. Use of a longer-acting paralytic such as rocuronium makes this potential scenario even more plausible.
A group of authors recently published in Critical Care Medicine a prospective multicenter cohort study to further add to the knowledge available on this topic.
Just under 400 patients were involved in the study, and 3.4% of them experienced awareness with paralysis.
Of the patients who experienced awareness with paralysis, all but one of them receive rocuronium as the neuromuscular blocker for RSI.
Patients who experienced awareness with paralysis also had a significantly higher mean threat perception scale score, which suggests a higher risk of post-traumatic stress disorder in these patients.
The authors concluded:
AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.
The 3.4% rate of awareness with paralysis is far in excess of the reported incidence in OR patients which is just 0.1%. This suggests there is tremendous need and room for improvement in ED patients, and the multicenter nature of this study strengthens its applicability to other practice sites. Rocuronium, with its longer duration of action, should heighten a clinician’s awareness of the need to take steps to prevent awareness with paralysis.
Members of my Hospital Pharmacy Academy have access to practical training on preventing awareness with paralysis from a pharmacist’s point of view, as well as training on airway pharmacology and over 200 other topics relevant to hospital practice. To get immediate access go to pharmacyjoe.com/academy.
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