In this episode, I’ll discuss using clinical decision support to minimize sedation gaps in patients receiving rocuronium for rapid sequence intubation.
Awareness with paralysis in ED patients who receive the long-acting paralytic rocuronium during rapid sequence intubation but have a delay in receiving adequate sedation is a continuing area of concern. This is a topic that was discussed in episodes 754, 867, 873, and 1008 largely from the point of view that a pharmacist at the bedside can help by keeping a focus on the need for timely sedation after rocuronium and successful intubation. However, a systems-level rather than personnel-dependent approach might also have a significant effect on reducing the chance of awareness with paralysis, and that is what a group of authors studied and published recently in AJHP.
The study was a retrospective, multicenter, observational, before-after study that included over 700 adult patients who received rocuronium for RSI. The authors evaluated sedation practices before and after the implementation of an RSI clinical decision support (CDS) update that linked sedation guidance to rocuronium orders. They analyzed the patients before and after implementation for coprimary outcomes of sedative selection and initial sedative dose within 1 hour after rocuronium administration. The secondary outcomes were time to sedative initiation, time to adequate sedation, and incidence of hypotension requiring vasopressors.
After CDS implementation, the following statistically significant outcomes occured:
- Propofol use increased from 56.8% to 73.1%,
- Initial propofol dose increased from a median of 5 µg/kg/min to 20 µg/kg/min
- Midazolam use decreased from 32.1% to 19.3%
- The median time to sedation initiation decreased 14 minutes to 12 minutes
- The median time to adequate sedation decreased from 32 minutes to 14 minutes
The incidence of new-onset hypotension was similar across groups, at 25%.
The authors concluded:
A CDS update linking sedation guidance to rocuronium orders resulted in faster initiation of higher doses of sedation after paralysis without increasing hemodynamic instability, supporting the use of CDS strategies in the peri-intubation period.
While the clinical decision support implemented in this multi-center study did have a major impact on adequate sedation rates, there is still considerable room for improvement to minimize the risk of awareness with paralysis.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Leave a Reply