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Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study*
Critical Care Medicine ( IF 8.8 ) Pub Date : 2022-10-01 , DOI: 10.1097/ccm.0000000000005626
Brian M Fuller 1 , Ryan D Pappal 2 , Nicholas M Mohr 3 , Brian W Roberts 4 , Brett Faine 5 , Julianne Yeary 6 , Thomas Sewatsky 4 , Nicholas J Johnson 7 , Brian E Driver 8 , Enyo Ablordeppey 1 , Anne M Drewry 9 , Brian T Wessman 1 , Yan Yan 10 , Marin H Kollef 11 , Christopher R Carpenter 12 , Michael S Avidan 13
Affiliation  

OBJECTIVES: 

In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence.

DESIGN: 

An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial.

SETTING: 

The ED of three academic medical centers.

PATIENTS: 

Mechanically ventilated adult patients that received neuromuscular blockers.

INTERVENTIONS: 

None.

MEASUREMENTS AND MAIN RESULTS: 

All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% (n = 13), the majority of whom received rocuronium (n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% (n = 12/230) experienced AWP, compared with 0.6% (n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11–67.15). Patients experiencing AWP had a higher mean (sd) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01).

CONCLUSIONS: 

AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.



中文翻译:

急诊科危重患者对瘫痪的认识:一项前瞻性队列研究*

目标: 

对于机械通气患者,麻痹意识 (AWP) 可能会产生毁灭性后果,包括创伤后应激障碍 (PTSD)、抑郁症和自杀念头。来自急诊科 (ED) 的单中心数据表明 AWP 因素的事件发生率高于手术室报告的事件发生率。然而,仍然缺乏重症机械通气患者 AWP 的数据。目的是评估经历 AWP 的 ED 患者比例,并调查与其发生相关的可修改变量。

设计: 

对多中心、前瞻性、临床试验前后进行先验计划的二次分析。

环境: 

三个学术医疗中心的急诊室。

患者: 

接受神经肌肉阻滞剂的机械通气成年患者。

干预措施: 

没有任何。

测量和主要结果: 

收集与镇静和镇痛相关的所有数据。AWP 是主要结果,采用修改后的 Brice 问卷进行评估,并由三名专家评审员独立判定。在 PTSD 的因果路径中,感知到的威胁是次要结果。总共对 388 名患者进行了研究。经历 AWP 的患者比例为 3.4% ( n = 13),其中大多数接受罗库溴铵治疗 ( n = 12/13; 92.3%)。在接受罗库溴铵治疗的患者中,5.5% ( n = 12/230) 经历过 AWP,而在急诊室未接受罗库溴铵治疗的患者中,这一比例为0.6% ( n = 1/158)(比值比,8.64;95% CI,1.11) –67.15)。与未经历过 AWP 的患者相比,经历过 AWP 的患者的平均 ( SD ) 威胁感知量表得分较高(15.6 [5.8] vs 7.7 [6.0]; p < 0.01)。

结论: 

AWP 存在于机械通气 ED 患者中的比例令人担忧,与 ED 中罗库溴铵暴露相关,并导致感知威胁水平增加,使患者面临更大的 PTSD 风险。迫切需要开展旨在进一步量化这一弱势群体中 AWP 并消除其发生的研究。

更新日期:2022-09-17
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