How Bad is It?

NAP5 Study

See the NAP5 Site


Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study


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?

How to Fix the Problem

  1. If you are not in a high-performance Resus shop–USE SUX!!!
  2. Have Propofol and NORepi brought into the room and set them up while intubating
  3. If reducing the dose of induction or pt has high BMI, use DSI [See Morbid Obesity Ep.]
  4. 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
    1. For most patients, 33 mcg/kg/min is just enough to get amnesia, not even adequate sedation.
    2. The image below is an attempt for a MAC of propofol when dosed with opioids–much higher than what we are used to using
  5. Give opioids as well
  6. Consider giving amnestic dose of midazolam to any patient receiving rocuronium
  7. In the ICU, if planning on continued paralysis for ARDS, consider
    1. Multiple sedative agents if concern for PRIS leads to inadequate propofol dosing
    2. Consider sedation monitors
    3. Consider TIVA apps to calculate needed doses
  8. Never lower sedation for hemodynamics during paralysis–instead give inopressors

Additional Information

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