Long-acting Neuromuscular Paralysis Without Concurrent Sedation in Emergency Care

Am J Emerg Med. 2014 May;32(5):452-6. doi: 10.1016/j.ajem.2014.01.002. Epub 2014 Jan 15.


Objective: Neuromuscular 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.

Methods: We 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.

Results: Over 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.

Conclusion: Absence 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.

MeSH terms

  • Adult
  • Aged
  • Emergency Medical Services*
  • Emergency Service, Hospital*
  • Female
  • Humans
  • Hypnotics and Sedatives / administration & dosage
  • Intubation, Intratracheal*
  • Male
  • Middle Aged
  • Neuromuscular Blockade / methods*
  • Neuromuscular Blocking Agents / administration & dosage*
  • Respiration, Artificial
  • Retrospective Studies


  • Hypnotics and Sedatives
  • Neuromuscular Blocking Agents