Optimizing Administration and Timing of Post Intubation Analgesia and Sedation in the Emergency Department

Introduction: Recent literature suggests pain management and sedation in ED patients after rapid sequence intubation are done inconsistently, which impacts patient outcomes negatively. The purpose of this study is to compare rates and timing of post-intubation analgesia and sedation before and after an ED pharmacy practice improvement intervention.

Methods: We conducted a retrospective study of adult ED patients intubated over an 18-month period. The primary study endpoint was the frequency of post-intubation analgesia and sedation administration before and after implementation of the post-intubation guideline and education. Secondary endpoints included time to analgesia and sedation medication after paralytic administration, comparison between paralytic drugs utilized (succinylcholine and rocuronium), and ED length of stay.

Results: Prior to intervention, the mean percentage of post-intubation analgesia and sedation administration was 58.6% and 94.3%, respectively. After paralytic administration, the time to dose of analgesia was 63 minutes (range 0-288) and 47 minutes for sedation medication (range 0-214). The mean length of stay in the emergency department was 298 minutes (range 12-3143). Following the intervention, 35 patients met inclusion criteria, and the mean percentage of analgesia and sedation administration was 77.1% and 91.4%, respectively. The mean time to analgesia administration improved to 22 minutes (range 0-123), and sedation improved to 20 minutes (range 0-284). The mean emergency department length of stay decreased to 204 minutes (range 46-469). When comparing paralytic used, mean time to analgesia and sedation was longer in those who received rocuronium compared to succinylcholine.

Discussion: An educational lecture along with a novel ED post-intubation clinical guideline improved rates and timing to analgesia and sedation. This provides a unique opportunity for emergency nurses to advocate for early analgesia and sedation in mechanically ventilated patients.