Strategies to prevent awareness with paralysis following administration of neuromuscular blocking agents

Awareness with paralysis (AWP) is an increasingly recognized complication of neuromuscular blocker use and is associated with adverse patient experiences. This manuscript describes the incidence of AWP and mitigation strategies that can be employed to prevent its occurrence and ensure optimal patient care.

Preventative strategies are essential to reduce the incidence of AWP. Approaches for prevention include awareness of the duration of action of analgesics, sedatives, and neuromuscular blocking agents (NMBAs), timely administration of postprocedural sedation, use of NMBAs for the shortest duration possible, and monitoring of the depth of sedation and neuromuscular blockade. Pharmacists are integral members of the multidisciplinary team in the emergency department and intensive care unit, where nonoperative neuromuscular blocker use is most common. Pharmacists can play a key role in eliminating AWP through their knowledge of the pharmacokinetics and pharmacodynamics of sedatives and NMBAs and their role in medication selection and monitoring.

By applying key strategies to prevent AWP, pharmacists can help make AWP a never event in both procedural and continuous use of NMBAs.