In this episode, I’ll discuss the frequency of awareness with paralysis in the ED.
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.
After extubation, the authors assessed patients for awareness with paralysis by using the modified Brice questionnaire. Ten of the patients had awareness with paralysis for a prevalence of 2.6%.
The odds ratio for paralysis with awareness with rocuronium was 5.1 compared to succinylcholine.
This single-center study suggests a significant number of patients may experience awareness with paralysis, and that use of rocuronium may raise the risk of this happening in the ED. A pharmacist in the ED is well suited to ensuring the prompt provision of analgosedation after RSI and thereby prevent awareness with paralysis from occurring. While the rest of the care team is confirming tube placement, CO2 exchange, and stabilizing the patient, the pharmacist can remain focused on the continued sedation and comfort of the patient.
Members of my Hospital Pharmacy Academy have access to my Airway Pharmacology Masterclass, 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.