Raymond Hau, PharmD,
Critical Care Pharmacist
Greenwich Hospital
Greenwich, Connecticut
Disclosure information not submitted.
Mahmoud Ammar, BCCCP, PharmD, BCPS,
Critical Care Pharmacist
Yale New Haven Hospital
New Haven, Connecticut
Disclosure information not submitted.
Michael Liu, PharmD, BCPS, BCCCP, BCNSP
Assistant Dean of Clinical & Professional Affairs
Touro College of Pharmacy, United States
Disclosure information not submitted.
Bryan McGill, PharmD, BCPS, BCCCP
Senior Clinical Pharmacy Specialist, Critical Care
Yale New Haven Hospital, United States
Disclosure information not submitted.
Title: Evaluation of Sedation and Analgesia with the Use of Neuromuscular Blocking Agents
Introduction: During the COVID-19 pandemic, continuous infusion neuromuscular blocking agents (NMBA) were frequently utilized. International guidelines for NMBA use in critically ill patients recommend patients achieve deep sedation using a continuous sedative and analgesic prior to and during neuromuscular blockade, and documentation is essential to confirm adequate sedation. The aim of this evaluation was to assess the use of sedation and analgesia in paralyzed patients.
Methods: A retrospective multi-center study was performed on fifty adult patients randomly selected from five hospitals across the health system based on the proportion of patients on NMBA at each delivery network. Patients were included if they received a continuous infusion NMBA between March 24 and May 8, 2020. The primary outcome was documentation of adequate sedation and analgesia prior to NMBA initiation, defined as a Richmond Agitation-Sedation Scale (RASS) -4 to -5 while receiving both sedative and analgesic infusions. Secondary outcomes included RASS documentation within 2 hours prior to and bispectral index (BIS) 2 hours after NMBA initiation, and incidence of medication orders updated with appropriate sedation goal.
Results: We identified 21 (42%) patients with documentation of adequate sedation and analgesia prior to NMBA initiation. Adequate sedation was documented in 22 (44%) patients, with 24 (48%) not at goal, 3 (6%) not documented, and 1 (2%) without a continuous sedative order. Adequate analgesia was documented in 39 (78%) patients, with 8 (16%) having as-needed intravenous (IV) push opiates orders and 3 (6%) without analgesia orders. Medication orders were updated with appropriate sedation goal in 2 (4%) patients. Documentation of sedation was completed within 2 hours of NMBA initiation in 25 (50%) patients and in 18 (36%) 2 hours after initiation.
Conclusions: Electronic health records should be optimized to facilitate ordering appropriate sedation and analgesia with appropriate titration parameters, and to ensure that an appropriate level of sedation is documented prior to NMBA initiation. Adequate documentation may have been limited due to BIS monitor availability and medication orders with outdated titration parameters.