Beware of Paralysis Awareness

The prevalence of post-intubation awareness of paralysis is estimated to be 2.6%


?Why does this matter

The anesthesia literature has thoroughly studied post-intubation awareness of paralysis in the operating room.  The risk factors for post intubation awareness include IV induction, underdosing of anesthesia, administration of long-acting paralytics, and lack of sedation monitoring systems.  Awareness of paralysis has been proven as a perceived threat and contributes to depression, anxiety, and PTSD.  There has never been a large study looking at this in the ED… until now.

ED-AWARENESS: The prevalence is higher than you might think
This was a single center, prospective study performed in a large, tertiary, academic facility on adult patients without traumatic brain injury or death while on the ventilator.  383 patients were included. The methods of determining whether the patients experienced awareness in the ED after paralysis were rigorous, including administration of a validated questionnaire and 3 expert reviewers who deliberated over each case.  10/383 (2.6%) were deemed to have experienced awareness.  The perceived threat from each case further implies the chilling nature of paralysis (the quotes from the patients in this study are worth a read!). This facility uses rocuronium about 70% of the time, and rocuronium was found to have an increased risk of awareness (OR 5.1, 95%CI 1.30-20.1).  My takeaway is to be wary of ED paralysis awareness, dose induction agents properly, order post-intubation sedation prior to intubation, and set sedation goals with nursing.

The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021 May;77(5):532-544. doi: 10.1016/j.annemergmed.2020.10.012. Epub 2021 Jan 21.

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