The Pre-brief
Paralysis without sedation causes significant psychological harm to patients. This rarely happens in the controlled setting of an operating room, the ED-AWARENESS study by Pappal et al demonstrated that this may be occurring more often in emergent intubation settings.
Know the Duration of Action
When dosing a paralytic agent, we must know the duration of action of both the paralytic agent and the sedative agent. As the dose of Rocuronium is increased, the duration of action also increases. A dose of 2mg/kg of rocuronium will keep a patient paralyzed for almost 2 hours.
*Editor’s Commentary
The duration of action may be longer in patients with hepatic and renal dysfunction (i.e. most people I intubate).
-Siuba
Start Sedation Early.
Especially if you are using a long acting paralytic such as rocuronium, you should start ongoing analgesia and sedation immediately after dosing your paralytic agent. An awake, paralyzed patient may become tachycardic and hypertensive, but they will not move.
The Debrief
- Paralysis without sedation causes psychological harm to patients.
- Known the duration of action of the paralytic and sedative agents you use
- When dosing a long acting paralytic, start infusions of analgesia and sedation immediately after dosing your paralytic.
References
- Pappal RD, Roberts BW, Mohr NM, Ablordeppey E, Wessman BT, Drewry AM, Winkler W, Yan Y, Kollef MH, Avidan MS, Fuller BM. 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. PMID: 33485698.
- Heier T, Caldwell JE. Rapid tracheal intubation with large-dose rocuronium: a probability-based approach. Anesth Analg. 2000 Jan;90(1):175-9. doi: 10.1097/00000539-200001000-00036. PMID: 10625000.
- Rosenbaum SB, Gupta V, Palacios JL. Ketamine. [Updated 2021 Feb 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470357/
- Folino TB, Muco E, Safadi AO, et al. Propofol. [Updated 2020 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430884/
- Vahedi HSM, Hajebi H, Vahidi E, Nejati A, Saeedi M. Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury. World J Emerg Med. 2019;10(1):27-32. doi: 10.5847/wjem.j.1920-8642.2019.01.004. PMID: 30598715; PMCID: PMC6264977.
