ORIGINAL RESEARCH|ARTICLES IN PRESS

Recall of awareness during paralysis among emergency department patients undergoing tracheal intubation

Brian E. Driver, Matthew E. Prekker, Emily Wagner, et al

Chest Published:September 08, 2022

DOI:https://doi.org/10.1016/j.chest.2022.08.2232

ABSTRACT

Background

Critically ill patients sometimes remember periods of neuromuscular blockade.

Research Question

What is the prevalence of recalled awareness during paralysis in patients who received emergency tracheal intubation and mechanical ventilation and what clinical variables are associated with this outcome?

Study Design and Methods

We analyzed data from a prospectively-collected continuous quality improvement database of emergency tracheal intubation in an urban, county hospital. Patients who received a neuromuscular blocking agent to facilitate emergency tracheal intubation in the emergency department were included. The database included details of intubation management including medications received and patient mental status before intubation. Patient recall of awareness of paralysis was assessed by trained staff during an in-person interview after extubation using a modified Brice questionnaire. For this analysis, three expert reviewers used these data to adjudicate whether patients may have had awareness of paralysis, the primary outcome. We constructed a logistic regression model to determine whether clinical variables were associated with the primary outcome.

Results

A total of 886 patients were analyzed. There were 66 patients (7.4%, 95% CI 5.8%–9.4%) determined to possibly (61 patients) or definitely (5 patients) have experienced and recalled awareness of paralysis. A logistic regression model showed that a decreased level of consciousness before intubation was associated with lower odds of awareness (adjusted odds ratio 0.39 [95% CI 0.22 - 0.69]), while the class of neuromuscular blocking agent used, sedative used, pre-intubation shock index, and post-intubation sedation were not significantly associated with recall of this outcome.

Interpretation

Among patients intubated emergently using a neuromuscular blocking agent, 7.4% of patients recalled awareness without being able to move, which was more likely when patients had a normal level of consciousness before intubation.