title: Long-acting neuromuscular paralysis without concurrent sedation in emergency care.
abstract: OBJECTIVE
  Neuromuscular paralysis without sedation is an avoidable medical error with negative psychologic and potentially physiologic consequences. We determine the frequency of long-acting paralysis without concurrent sedation among patients intubated in our emergency department (ED) or before arrival.
  
  
  METHODS
  We performed a retrospective cohort study from July 2007 to August 2009. We chose this time interval because in 2006, our institution developed a multidisciplinary plan designed to improve care of intubated patients. We identified all mechanically ventilated patients using billing codes. We reviewed all records to identify use of long-acting neuromuscular blocking agents. We captured data on patient characteristics and location of intubation, using a standardized data collection form. We report bivariate risk ratios to quantify associations with lack of concurrent sedation. A priori, we defined concurrent sedation as administration of any sedative during the 60 minutes preceding and the 15 minutes after administration of the long-acting paralytic.
  
  
  RESULTS
  Over the 26-month period of study, 292 patients received a long-acting paralytic. Of the 212 available for analysis, 39 (18%) did not receive concurrent sedation. Every decade of age increased the risk of paralysis without concurrent sedation by 1.2 (95% confidence interval [CI], 1.1-1.4). Paralysis for intubation (vs for transport or ventilation management) increased the odds of no sedation by 2.1 (95% CI, 1.2-3.7). No other covariates predicted nonsedation.
  
  
  CONCLUSIONS
  Absence of concurrent sedation was common among patients receiving long-acting neuromuscular paralysis before arrival or at our ED, despite implementation of a guideline to improve practice.
authors.affiliation: Stanford/Kaiser Emergency Medicine Residency Program, Stanford, CA.
authors.forename: Ian D
authors.initials: ID
authors.lastname: Chong
authors.affiliation: Department of Emergency Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Sandefur
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
authors.forename: Dorothy E
authors.initials: DE
authors.lastname: Rimmelin
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
authors.forename: Christian
authors.initials: C
authors.lastname: Arbelaez
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
authors.forename: Calvin A
authors.initials: CA
authors.lastname: Brown
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
authors.forename: Ron M
authors.initials: RM
authors.lastname: Walls
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Electronic address: dpallin@partners.org.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Pallin
mesh_terms: D000328:Adult; D000368:Aged; D004632:Emergency Medical Services; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D019148:Neuromuscular Blockade / Q000379:methods*; D009466:Neuromuscular Blocking Agents / Q000008:administration & dosage*; D012121:Respiration, Artificial; D012189:Retrospective Studies
chemical_list: D006993:Hypnotics and Sedatives; D009466:Neuromuscular Blocking Agents