Mind the Gap

Background

Induction agents are administered to decrease the risk of discomfort, awareness, and psychological sequelae during procedural paralysis (eg, rapid sequence intubation). The expected duration of nondepolarizing neuromuscular blocking agents exceeds that of induction sedatives. The resulting sedation gap may increase the risk of awake paralysis.

Research Question

The objective of this study was to elucidate the prevalence and duration of sedation gaps in critically ill patients undergoing bedside procedural paralysis.

Study Design and Methods

This was a retrospective cross-sectional study of critically ill adults who received rocuronium for a bedside procedure. The primary outcome was the sedation gap, which was the cumulative time of inadequate sedation during presumed paralysis (ie, 60 min after rocuronium). Secondary outcomes included the sedation gap when a pharmacist was present at the bedside. Descriptive statistics were used for baseline characteristics and the primary outcome. Log-rank and Mann-Whitney U tests were used to analyze secondary outcomes.

Results

Eighty patients were included in the final analysis. The average age was 60 years and 57% of patients were male. The most common indication for procedural paralysis was rapid sequence intubation (99%). Most procedures were performed in the ED (55%), followed by the ICU (43.8%). Eighty-five percent of patients experienced a sedation gap of any duration. The median sedation gap was 19 min (interquartile range [IQR], 4-47.5 min). The probability of initiating adequate sedation was higher when a pharmacist was present at the bedside (hazard ratio, 1.49 [95% CI, 1.42-1.55], bootstrapping log-rank test). The median sedation gap with a pharmacist (11 min [IQR, 3-27.5 min]) was significantly lower than without a pharmacist (40 min [IQR, 17-55 min]; P = .0115, Mann-Whitney U test).

Interpretation

In this critically ill cohort, a substantial prevalence and duration of inadequate sedation was experienced after receiving rocuronium for bedside procedures. Further study is needed to identify if sedation gaps correlate with an increased risk of psychological morbidities.