Imagine lying in a hospital bed, awake and alert during a procedure such as mechanical ventilation — yet unable to speak, move, or signal distress. This harrowing experience is known as awareness with paralysis (AWP), a growing concern linked to the use of neuromuscular-blocking agents.
Researchers explored how pharmacists can help prevent this potentially devastating condition in a recently published report in AJHP written by Dusty Linn, Megan Rech, and Brett Faine.
Studies have shown up to 7% of patients experience AWP, said Rech, a research health scientist and clinical pharmacist specialist at the Edward Hines Jr. VA Hospital in Hines, Illinois.
Patients may recall sounds or sensations, including pain, while paralyzed. Some have reported that they believed they were dying in bed, Rech said.
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“This is really important, because patients can have post-traumatic stress disorder. They can have anxiety and depression afterwards, and suicidal thoughts,” Rech said. “We want to mitigate that so they’re not experiencing that distress downstream.”
The condition most often occurs during rapid sequence intubation — when the duration of action of the paralytic, or neuromuscular blocking agent, exceeds the duration of action of the induction agent administered, along with delayed sedation administration said Linn, a field medical director at Phillips in hospital patient monitoring and a critical care pharmacist at Parkview Regional Medical Center in Fort Wayne, Indiana.
AWP may also result from inadequate sedation strategies or development of tolerance to sedation in cases of continuous neuromuscular blocker administration, he said.
Hundreds of thousands of patients require mechanical ventilation in emergency departments and intensive care units each year, the authors said, but AWP has only recently started being tracked in those settings, said Faine, a clinical associate professor of emergency medicine and pharmacy at the University of Iowa. Most prior research has focused on operating rooms, Linn noted.
The good news? Pharmacists can take several steps to help reduce the chance of AWP, the authors said.
Those strategies include knowing the duration of action for the medications used, using neuromuscular-blocking agents for the shortest duration possible, offering timely administration of postprocedural sedation, and monitoring for the depth of sedation and neuromuscular blockade.
“Pharmacists can play a key role in eliminating AWP through their knowledge of the pharmacokinetics and pharmacodynamics of sedatives and neuromuscular-blocking agents and their role in medication selection and monitoring,” the researchers wrote.
Pharmacists can select a shorter-acting paralytic like succinylcholine for intubation if there are no contraindications and then ensure initiation of post-intubation sedation and analgesia as soon as possible, Rech advised.
While it’s unlikely that AWP could become a “never event,” pharmacists should continue to evaluate targeted interventions to ensure these events are extremely rare, the authors said.
The report arose from Linn’s interest in neuromuscular monitoring practices. “Neuromuscular monitoring isn’t typically employed after administration of neuromuscular blocking agents during rapid sequence intubation, and therefore, we don’t know exactly how long the agents that we use for RSI may last,” he said. “It’s very difficult to identify AWP during paralysis, because patients can’t move or react. Most of the research has identified it through surveys after the fact.”
Patients should be monitored for sedation and for depth of neuromuscular blockade, Linn said. For sedation, clinicians could use some type of brain function monitoring such as bispectral index, which gives a numeric readout of how deeply a patient is sedated.
“That can tell us that we’ve achieved an adequate depth of sedation so that there’s a low probability of spontaneous recall,” he said. Monitoring neuromuscular activity can indicate when patients have fully recovered from blockade, at which point the sedation could be lightened with much less concern about AWP.
One tool available is train of four, a method of electrically stimulating a nerve in the arm and viewing muscle contractions, he said. If a patient has four twitches, the effects of neuromuscular blockade are less pronounced.
“Pharmacists are really essential for medication selection and dosing during rapid sequence intubation and during continuous paralysis,” Linn said. “Pharmacists can help in a number of ways through initial selection and adequate dosing, as well as educating medical teams on the duration of action of different sedatives and neuromuscular blocking agents that have been administered.”
Clinicians, including pharmacists, often assume patients are properly sedated if they’re not moving, explained Megan Musselman, an emergency medicine pharmacy clinical specialist and coordinator and postgraduate year 2 emergency medicine pharmacy residency program director at NKC Health in Kansas City, Missouri, who also has studied the condition. She or a pharmacy colleague responds to every rapid sequence intubation in the ED and is at the bedside to help facilitate medications.
“Whenever we have to use medications to help facilitate somebody being intubated, we have to use paralytics,” she said. “We have different agents we use. Some are very short-acting and one is very long-acting.”
Literature that has emerged since the early 2020s suggests patients are most vulnerable right after intubation, which frequently is in the emergency department, she said.
“We need to be better about monitoring adequate sedation and our dosing and timing,” Musselman said. “What’s great is, this is really showing the impact that pharmacists have in reducing these downstream effects. We really do play a pivotal role.”
Linn discussed the article in a recent podcast. ASHP also has webinars on Rapid Sequence Intubation in Special Patient Populations and Procedural Sedation and Analgesia in the Emergency Department.
