CRITICAL CARE MEDICINE SECTION
Post Intubate Awareness While Paralyzed and How to Avoid It Kirstin Acus, MD,* Cara Gardner, MS,† and David Gordon, MD‡
A
patient’s hospital course upstairs is heavily impacted by the care they received downstairs. Countless studies—from the LOV-ED trial, which showed that implementation of lung protective ventilatory strategies in the emergency department (ED) led to improved patient outcomes of ventilator-associated complications and decreased mortality to a recent trial published in 2022 that revealed that performing fascia iliaca blocks in the ED led to decreased overall opioid consumption, hospital length of stay, and hospital readmission rates for patients suffering from hip fractures—have proved this time and time again.1,2 The purpose of this article is to investigate how the quality of sedation a person receives in the ED affects their outcomes and outline protective strategies for sedation in the ED. Sedation depth in the ED has a clear influence on patient outcomes and what happens upstairs. A 2017 observation study found that deep sedation in the ED can mean taking 48 hours to get to the appropriate sedation level in the ICU, and is associated with an increase in mortality.3 However appropriate depth sedation is attainable in the ED, with minimal intervention. A recent prospective multicenter pilot trial, which included 415 patients, evaluated patients in a before and after fashion of reinforcing in-house sedation procedures. Simply through this reinforcement, the rate of sedation documentation in the ED increased 64.8% to 88.6% (P<0.01), RAAS increased from -3 to -2, deep sedation decreased from 60.2% to 38.8% (P<0.01), light sedation increased from 49.2% to 69.1% (p<0.01), ventilator-free days increased from 19.9 to 22.0 (P=0.03), ICU days went from 18.1 to 20.8 (P<0.01), and mortality decreased from 20.4% to 10.0% (P<0.01) (though the pre-intervention cohort was sicker; all of this with an increase of only 1 inadvertent extubation, none (2 in the pre- intervention versus 3 in the post- intervention group), none of which needed to be intubated. What makes this even more impressive is that overall the frequency of drugs used did not change much (though ketamine was used less), but cumulative doses of fentanyl and ketamine both increased when used. Surprisingly, Midazolam was used roughly 20% of the time and was continued in the ICU, though at the site where it was used most frequently it was used only as a bolus. Additionally, while day one deep sedation in the ICU did not statistically differ between the two groups, day two deep sedation was less common in the intervention group 32.1% vs 22.3% (p=0.04). Of course, as the authors of this study remind us, this is only a pilot trial, but does it does hint that a more mindful approach to our sedation practices can have a big impact on patent’s ICU care and outcomes.4 In addition, every emergency provider needs to be aware of the potentially devastating impact of not providing adequate sedation to patients post-intubation—awareness while paralyzed (AWP). Using the Brice Modified Questionnaire, the 2021 EM-Awareness study found that 2.6%
38
COMMON SENSE JANUARY/FEBRUARY 2023
of their patient population experienced AWP.5 A similar rate of AWP was found in an apriori pre-planned secondary analysis of the ED-SED trial using the same methodology as the EM-Awareness study, AWP was found in 13 out of 388 patients for a rate of 3.4%.6 Rocuronium was the most notable risk factor in both studies.5,6 Patients who experience AWP are at a high risk of developing long-term detrimental psychological outcomes including post-traumatic stress disorder, complex phobias, and clinical depression.7 In order to avoid both over and under sedation moving forwards, we must take a thoughtful and individualized approach to sedation. First, sedation should be part of the set-up preparation for intubating patients, especially if using rocuronium. In regards to choice of agents, a bolus dose of midazolam will provide both amnesia and is likely hemodynamically neutral. For analgesia, a fentanyl drip or a bolus of hydromorphone are reasonable options. Following the Midazolam, an infusion of precedex, propofol, or ketamine is reasonable and should be available immediately after intubation. Continuous infusion of benzodiazepines has fallen out of favor due to concerns for increased delirium.8 When it is clear that paralytics have worn off, sedation should be targeted to a Richmond Agitation Sedation Scale (RASS) of 0- -2 (between alert but calm and lightly sedated). While some patients may not require sedation, the immediate post-intubation sedation should be started and the need to be reassess when patient is stabilized. Agents should be chosen to address that patient’s individual needs and if a no sedation approach is taken, analgesia may need to be increased.9 Getting the appropriate sedation in the ED, only requires minimal effort as long as a conscious effort and preparation is made. Practicing evidence-based medicine regarding post intubation sedation will lead to major improvement for patient outcomes in the ED, ICU, and even after discharge. References * Hartford Hospital † Kirksville College of Osteopathic Medicine ‡ Medstar Washington Hospital Center 1. Fuller, Brian M., Ian T. Ferguson, Nicholas M. Mohr, Anne M. Drewry, Christopher Palmer, Brian T. Wessman, Enyo Ablordeppey, et al. “LungProtective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial.” Annals of Emergency Medicine 70, no. 3 (September 2017): 406-418.e4. https://doi.org/10.1016/j. annemergmed.2017.01.013. 2. Kolodychuk, Nicholas, John Collin Krebs, Robert Stenberg, Lance Talmage, Anita Meehan, and Nicholas DiNicola. “Fascia Iliaca Blocks Performed in the Emergency Department Decrease Opioid Consumption and Length of Stay in Patients with Hip Fracture.” Journal of Orthopaedic Trauma 36, no. 3 (March 1, 2022): 142–46. https://doi.org/10.1097/ BOT.0000000000002220. >>