Guideline-Concordant Sedative and Analgesia Use in Critically Ill Patients Receiving Sustained Neuromuscular Blockade

Given significant harms of awake paralysis, guidelines recommend combination sedation and analgesia during neuromuscular blockade. In this study, we sought to describe guideline-concordant use of parenteral sedation and analgesia during sustained neuromuscular blockade among adults with critical illness.

Multicenter, retrospective cohort study.

ICUs in 871 hospitals across the United States.

Adult patients admitted to an ICU between 2016 and 2022 who received invasive mechanical ventilation and at least one neuromuscular blocking agent (NMBA) on the same calendar day.

None.

We used charge codes to identify use of parenteral sedatives (propofol, fospropofol, lorazepam, midazolam, diazepam, etomidate, phenobarbital, pentobarbital, and ketamine), and analgesics (fentanyl, hydromorphone, morphine, and ketamine) for each patient-day with neuromuscular blockade, and then categorized patient-days as guideline concordant or not. A total of 363,382 patient-days (among 104,984 hospitalizations) were included in the final cohort. Guideline-concordant sedation and analgesia were used concurrently in 345,660 patient-days (95.1%); only sedation was used in 15,618 patient-days (4.3%), only analgesia was used in 1,348 patient-days (0.4%), and neither sedation nor analgesia was used in 756 patient-days (0.2%). Most included hospitals (856 [98.3%]) used both sedation and analgesia on greater than or equal to 50% of patient-days; however, ten hospitals (1.1%) used only sedation on greater than or equal to 50% of patient-days, and 4 (0.6%) had no predominant sedation and analgesia strategy; however, 42.3% of the variation in guideline-concordant practice was attributable to residual unexplained clustering by hospital after accounting for demographics, severity of illness, and hospital characteristics.

Our findings suggest sedation and analgesia practices with NMBA use in adult ICUs are generally guideline-concordant but require corroboration using more precise, quantitative medication data. Practice variation between hospitals is potentially concerning and warrants further investigation targeting adequacy of sedation and analgesia during NMBA use and assessing the clinical impact of guideline-discordant practices.