(980) Bridge the Gap: Effect of a Clinical Support Tool on Inadequate Sedation After Procedural Paralysis

Introduction: Neuromuscular blocking agents (NMBAs) are frequently used to achieve paralysis to facilitate rapid sequence intubation (RSI). Sedative agents are concurrently administered to mitigate the risk of discomfort and awareness. Past studies have revealed prolonged sedation gaps following administration of NMBAs. The primary objective was to evaluate the effect of a clinical decision support tool on sedation gap in critically ill patients that received NMBAs for bedside procedures.

Methods: This was a retrospective, pre-post study conducted at a large, academic medical center. Critically ill adults who received rocuronium for RSI during the study period (12/22 - 4/24) were included. The PRE cohort was comprised of patients that received RSI for bedside procedures prior to implementation of a clinical decision support tool. The POST cohort included patients that received RSI with coordinated administration of sedative and paralytic agents (3/24). The primary outcome was the cumulative sedation gap during presumed paralysis over a 60-minute period after NMBA administration. Secondary outcomes included probability and median time to initiation of adequate sedation. Descriptive statistics, Mann-Whitney U, Student’s t-test, and log-rank test were utilized for data analysis.

Results: There were 184 patients in the PRE and 60 patients in the POST group included in the final analysis. Demographic data were comparable between the PRE and POST groups. The average age was 60 years and 37% of the overall cohort was male. Most of the patients (55%) received RSI in the emergency department. For the primary outcome, the median cumulative sedation gap was significantly shorter in the POST group compared to PRE group (3 [IQR 0 - 14] vs 22 [IQR 3 - 50] minutes, p< 0.0001, Mann-Whitney U). The median time to adequate sedation was significantly shorter in the POST group (2 [IQR 0 - 6] vs 7 [IQR 1 - 43] minutes, p< 0.0001, Mann-Whitney U). The probability of initiating adequate sedation was significantly higher (HR = 1.99 [95% CI 1.92 to 4.36], p< 0.0001, log-rank) in the POST group.

Conclusions: A clinical decision support tool that couples NMBA and sedative orders significantly decreased the cumulative sedation gap and median time to adequate sedation in critically ill patients receiving RSI.