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Mounting Evidence that Paralysis Awareness is a Big Problem

October 4, 2022

Written by Aaron Lacy

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In this single center cohort of 886 patients, 5 patients had definite awareness during paralysis. However, there were 61 patients determined to have possible awareness, meaning upwards of 7.4% of patients could have been aware.

Why does this matter?
Paralysis awareness can lead to depression, anxiety, PTSD, and – honestly – would just be awful to experience. The first major report on paralysis awareness in ED patients found an estimated rate of awareness in 2.6% of patients. A follow up multicenter analysis found the number to be around 3.4%. More research on the topic can help us mitigate this horrific adverse event.

Is our understanding of paralysis awareness just the tip of the iceberg?
886 patients who underwent intubation at a U.S., urban, tertiary-care ED were screened for possible paralysis awareness using the Brice questionnaire. 66 patients (7.4%) had either possible (61) or definite (5) awareness during paralysis. A decreased level of consciousness immediately prior to intubation was associated with lower odds of awareness (aOR 0.39, 95%CI 0.22-0.69). Unlike the ED-AWARENESS and secondary analysis of the ED-SED Pilot trial, which both found rocuronium was associated with increased chance or paralysis awareness, this study saw no association between paralytic choice with awareness. There also was no association found between sedative use, pre-intubation shock index, and post-intubation sedative choice.

7.4% is 3 times higher than previously reported numbers of paralysis awareness. We want paralysis awareness to be a never event, but this study raises eyebrows that the problem might be more common than we previously realized and potentially harder to prevent than just using ‘adequate’ sedation. More information and studies are needed. In the meantime, I will focus on prompt and adequate sedative dosing before and after intubation.

Editor’s note: ED-SED warned against oversedation. Today, we promote sedation. Balance is key as are pre- and post-intubation checklists, including a sedation scale, like RASS, to help us target the right sedation depth. ~Clay Smith

Recall of awareness during paralysis among emergency department patients undergoing tracheal intubation. Chest. 2022 Sep 08. Doi: https://doi.org/10.1016/j.chest.2022.08.2232

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