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Don’t Forget the Sedation – A Paralytic Nightmare

August 8, 2022

Written by Jonathan Brewer

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The proportion of patients that experience awareness with paralysis (AWP) is alarmingly high; 3.4% were aware of their surroundings but paralyzed, which is 3.4% more than what should occur.

Why does this matter?
AWP can have devastating consequences, such as post-traumatic stress disorder (PTSD), depression, and suicidal thoughts. It is our duty as emergency physicians to ensure that we are providing adequate sedation with paralysis both before and after rapid sequence intubation (RSI). ED-AWARENESS found the rate of ED AWP was 2.6%. What did this multicenter cohort find?

Sedation, sedation, sedation
This was a secondary analysis of a multicenter, prospective, before-and-after clinical trial that included 388 mechanically ventilated adult patients that received neuromuscular blockers during the ED-SED Pilot Trial.

AWP was the primary outcome (assessed with the modified Brice questionnaire), with perceived threat (in the causal pathway for PTSD) as the secondary outcome. It was discovered that 13 patients (3.4%) experienced AWP with 12/13 of them (92.3%) receiving rocuronium (odds ratio 8.74; 95%CI 1.11-67.15). Those who experienced AWP also had a greater degree of perceived threat when compared with those without AWP: mean(SD), 15.6 (5.8) vs 7.7 (6.0); p < 0.01; a higher score from 0-21 meant greater threat perception.

What I take from this is that AWP was present in a concerning proportion of our paralyzed patients within the emergency department. When using a longer-acting paralytic (even rocuronium), it is imperative to remember adequate sedation. We have a large variety of sedatives and analgesics at our disposal, so there is no excuse to not sedate these patients.

Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med. 2022 Jul 22. doi: 10.1097/CCM.0000000000005626. Online ahead of print.

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