(1207) Mind the Gap: Inadequate Sedation Following Procedural Paralysis in Critically Ill Patients

Introduction: Induction agents are administered to decrease the risk of discomfort, awareness, and psychological sequelae during procedural paralysis (e.g., rapid sequence intubation (RSI)). The expected duration of non-depolarizing neuromuscular blocking agents (NMBAs) exceeds that of induction sedatives. The resulting sedation gap may increase the risk of awake paralysis during bedside procedures.
The objective of this study was to elucidate the prevalence and duration of sedation gaps in critically ill patients undergoing bedside procedural paralysis.

Methods: This was a retrospective, observational study of critically ill adults who received rocuronium for a bedside procedure. Patients were excluded if they received a) continuous sedation prior to procedure, b) serial NMBA bolus(es) or continuous infusions, c) or rocuronium in the context of cardiac arrest.
The primary outcome was the calculated sedation gap during presumed paralysis (i.e., 60 minutes after rocuronium). The sedation gap was defined as the interval of time between the end of induction sedation and the start of intermittent and/or continuous sedation. Secondary outcomes included the sedation gap when a pharmacist was present at 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% were male. The most common indication for procedural paralysis was RSI (99%). 85% of patients experienced a sedation gap of any duration. The median sedation gap during a 60-minute period of presumed paralysis was 19 minutes [IQR 4 - 49]. The probability of experiencing inadequate sedation was higher when a pharmacist was not present at bedside (HR 1.9 [95%CI 1.16 - 3.11], log-rank). The median sedation gap with a pharmacist (11 minutes [IQR 3 - 27.5]) was significantly lower than without (40 minutes [IQR 17 - 55], p=0.0127, Mann-Whitney U).

Conclusions: Critically ill patients in this cohort experienced a substantial rate and duration of inadequate sedation after receiving rocuronium for bedside procedures. Further study is needed to identify if sedation gaps correlate with an increased risk of psychological morbidity.