How Bad is It?
NAP5 Study
See the NAP5 Site
- In General Anesthetics with NMBs, the incidence was ~1:8000
- Higher for RSI but still in the 1:~600's range
Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study
[https://doi.org/10.1097/CCM.0000000000005626]
A planned secondary analysis of a multicenter, prospective, before-and-after clinical trial (ED-AWARENESS Study). The proportion of patients experiencing AWP was 3.4% (n = 13), the majority of whom received rocuronium (n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% (n = 12/230) experienced AWP, compared with 0.6% (n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11–67.15).
Why is this Occurring?
- Induction
- Maintenance after RSI
- Continued Therapeutic Paralysis in the ICU
How to Fix the Problem
- If you are not in a high-performance Resus shop–USE SUX!!!
- Have Propofol and NORepi brought into the room and set them up while intubating
- If reducing the dose of induction or pt has high BMI, use DSI [See Morbid Obesity Ep.]
- We are dosing too low on propofol during the paralyzed period. Start elderly at 20-30 mcg/kg/min, most patients should be on ~100 mcg/kg/min, may even need 200 mcg/kg/min for very young patients
- For most patients, 33 mcg/kg/min is just enough to get amnesia, not even adequate sedation.
- The image below is an attempt for a MAC of propofol when dosed with opioids–much higher than what we are used to using
- This study shows RIDICULOUSLY low doses of propofol post-tube
- Give opioids as well
- Consider giving amnestic dose of midazolam to any patient receiving rocuronium
- In the ICU, if planning on continued paralysis for ARDS, consider
- Multiple sedative agents if concern for PRIS leads to inadequate propofol dosing
- Consider sedation monitors
- Consider TIVA apps to calculate needed doses
- Never lower sedation for hemodynamics during paralysis–instead give inopressors
Additional Information
More on EMCrit
Updates
- Driver et al. just published another paper with similar findings [10.1016/j.chest.2022.08.2232]
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
- EMCrit RACC-Lit Review – March 2024 - March 28, 2024
Excellent thoughts on this topic; thank you for addressing it. FYI- the link to Dr Duggan’s full interview appears to be broken.
This was excellent, definitely an area for improvement with some very practical and immediately applicable tips! Really appreciate this and I’m sure our patients will as well!
thanks. very enlightening. our nurses frequently decrease the propofol for low bp.. ill stop this but should be ok if they are out of the paralysis zone? love the midazolam tip. I dont understand the chart with mg/kg/hour propofol doses. I thought they were in micrograms/kg/hour?
oops. I seethe prop dose is per hour as opposed to per minute. my bad
Hi Scott, This is a great discussion of such an important topic. I know so many places struggling with issues around staffing and skill mix, and as a consequence, the pendulum is likely to swing back to suxamethonium as the default paralytic of choice. I’d be keen to here from those who disagree, but certainly in the UK just now, we’re struggling, and the amount of additional work associated with rocuronium to ensure patients are adequately sedated means it’s likely those very high functioning departments (not sure who they are) are going to be capable of providing such a comprehensive… Read more »
Glad somebody studied this and is bringing awareness to the issue (pun unintended). It drives me crazy seeing so many people with neuromuscular blockade and horrifyingly low levels of propofol outside of the OR and nurses tell me things like, “50 mcg/kg/min is our max allowed rate” or “I’m not going to use high sedation if the patient’s not moving for me during my exams.”
What do you think of ketamine 1 mg/kg pushes q15-20 min for the first hour post roc-intubation (for a standard patient, no known alcohol hx)? The triple digit propofol rate may worry some of my ED team members…
I think this is an excellent idea. Should only need to 2 or 3 doses before Rocuronium paralysis wears off. Could even routinely give 1 dose post-intuition to buy time to get propofol drip set up.
*post-intubation.
Scott, does your shop or any other contributors have a “Post RSI” sedation protocol they would be willing to share that includes many of the variable approaches discussed. I hate cookie cutter medicine but a protocol may help lift not just the providers but the ancillary staffs approach. Great subject and discussion!
How to fix the problem? Call for anaesthesia in case of vital problems in ED.
Crit care intubations in first world countries should only be handled by highly skilled personell, which also understands the need for (processed) EEG monitoring during paralysis. Do not cowboy your way through the critical care.
Thank you for THIS podcast……
From a respiratory standpoint……
RESP gets “left” with a patient who isn’t adequately sedated,so the need for a blood gas looks like “a therapist trying to calm a patient”,yet begging for sedation & then pointing out “THE PT needed to be incubated & needs a scan,but the BP is low & the doc can give pressors”…….
So what does resp do? Leave & get called for vent alarms,or help RN/DOC with post intubation stabilization for need diagnostics???
Thank you for presenting this……
Scott, I can appreciate the severity of the post RSI awareness, although I will tell you as a member of P&T committee the dosing your suggesting is outside the given range for nursing. Typically most formularies have it maxed ~75mcg/kg/min. Some hospitals consider it anesthesia dosing and it is outside the realm of any provider except anesthesia. I also caution the usage of Propofol in any cardiogenic because it is quite the negative inotrope. As Always Appreciate your continue expertise.
Jeff–did you listen to the episode or just read the show notes?
Hey Scott. In fairness did not get a chance to listen to its entirety, just read through your notes. But you have my word I will listen, and I’ll get back to you. Appreciate your responses and input.
Excellent topic, too many abbreviations:0
As an anesthesiologist, I have a few comment that I hope may be helpful. 1) Narcotics are not amnestic. In my earlier years when I was doing cardiac anesthesia, we used extremely high doses of narcotics. An amnestic had to be added to the anesthetic in addition to the narcotic. Cardiac cases have some of the highest incidences of memory under anesthesia. 2) It obviously varies with institutions, but there may be some resistance to ordering up norepi in addition to propofol to maintain adequate amnesia post-rocuronium intubation and adequate blood pressure. I like this idea though. One option is… Read more »
thanks so much for commenting! Just wondering–are your comments in reference solely to the shownotes, or had you listened to the actual podcast