• Ian D Chong, Benjamin J Sandefur, Dorothy E Rimmelin, Christian Arbelaez, Calvin A Brown, Ron M Walls, and Daniel J Pallin.
• Stanford/Kaiser Emergency Medicine Residency Program, Stanford, CA.
• Am J Emerg Med. 2014 May 1;32(5):452-6.

ObjectiveNeuromuscular 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.MethodsWe 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.ResultsOver 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.ConclusionAbsence 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.Copyright © 2014 Elsevier Inc. All rights reserved.

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