Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study

Abstract

Objectives: In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence.

Design: An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial.

Setting: The ED of three academic medical centers.

Patients: Mechanically ventilated adult patients that received neuromuscular blockers.

Interventions: None.

Measurements and main results: All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01).

Conclusions: AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.

Trial registration: ClinicalTrials.gov NCT04410783.

Conflict of interest statement

Dr. Fuller is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) under award number R34HL150404. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Dr. Kollef is supported by the Barnes-Jewish Hospital Foundation. Funders played no role in the following features of the study: study design, data collection, data management, data analysis, data interpretation, writing of the article, or decision to submit the article for publication. Drs. Fuller’s, Mohr’s, and Roberts’ institutions received funding from the National Heart, Lung, and Blood Institute. Drs. Fuller, Mohr, Roberts, Faine, Drewry, and Yan received support for article research from the NIH. Dr. Drewry’s institution received funding from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Copyright © 2022 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Figures

Figure 1.

Study flow diagram