Analgesia and Sedation Related to the Use of Long-Acting Neuromuscular Blockers: A Narrative Review

Rapid sequence intubation is a standard procedure in critical care transport (CCT). Owing to its numerous benefits and clinical uses, rocuronium has become the first-line neuromuscular blocking agent in rapid sequence intubation, supplanting succinylcholine in many transport services. The deferred resumption of muscle activity with rocuronium may delay administering analgesia or sedation after intubation, resulting in awareness while paralyzed. We undertook a narrative review to evaluate this hazard in the existing literature. Numerous studies have revealed that 10% to 50% of intubated emergency department (ED) patients receive no sedation. Several retrospective reviews of intubated ED and transport patients found that the mean time to sedation or analgesia was longer for those receiving rocuronium than succinylcholine. Patients intubated with rocuronium in transport are more likely to receive neither analgesia nor sedation. Another study of a CCT program assesses data from 264 intubations, using a before and after model to analyze time to sedation after a formulary change from succinylcholine to rocuronium. Guidelines and prompts have not been successful at improving analgosedation systems. EDs have used pharmacists with success to improve post-intubation analgesia and sedation practices, but this is not feasible for transport. Although rocuronium has numerous benefits over succinylcholine for CCT systems, the existing literature demonstrates an ongoing risk of delays in sedation after intubation with rocuronium, with some patients not receiving any analgesia or sedation at all. Guidelines and prompts have not been successful, and ED solutions are impractical for the transport environment. Transport systems must remain vigilant for proper sedation after rocuronium administration.