Long-acting neuromuscular paralysis without concurrent sedation in emergency care

Neuromuscular paralysis without sedation is an avoidable medical error with negative psychologic and potentially physiologic consequences. We determine the frequency of long-acting paralysis without concurrent sedation among patients intubated in our emergency department (ED) or before arrival.

We performed a retrospective cohort study from July 2007 to August 2009. We chose this time interval because in 2006, our institution developed a multidisciplinary plan designed to improve care of intubated patients. We identified all mechanically ventilated patients using billing codes. We reviewed all records to identify use of long-acting neuromuscular blocking agents. We captured data on patient characteristics and location of intubation, using a standardized data collection form. We report bivariate risk ratios to quantify associations with lack of concurrent sedation. A priori, we defined concurrent sedation as administration of any sedative during the 60 minutes preceding and the 15 minutes after administration of the long-acting paralytic.

Over the 26-month period of study, 292 patients received a long-acting paralytic. Of the 212 available for analysis, 39 (18%) did not receive concurrent sedation. Every decade of age increased the risk of paralysis without concurrent sedation by 1.2 (95% confidence interval [CI], 1.1-1.4). Paralysis for intubation (vs for transport or ventilation management) increased the odds of no sedation by 2.1 (95% CI, 1.2-3.7). No other covariates predicted nonsedation.

Absence of concurrent sedation was common among patients receiving long-acting neuromuscular paralysis before arrival or at our ED, despite implementation of a guideline to improve practice.