You are the Paediatric doctor on call and receive a call for an incoming patient to the emergency department. A 12-year-old male is being transported by ambulance after a road traffic accident. His name is Ben. Ben has a possible skull fracture and has been intubated, but his oxygen requirement is minimal.
While waiting, another call comes in. Ben suddenly woke up and accidentally self-extubated. An attempt to re-intubate Ben was unsuccessful. Rocuronium (a muscle relaxant) alone was administered as he became combative. Another attempt led to an oesophageal intubation.
Ben was awake but paralysed. Tragically, several attempts at resuscitation upon arrival at the emergency department were unsuccessful.
This article is based on: Mayberry, H., Burgart, A.M. and Kanaris, C., 2021. Intubated, awake, and paralysed: a never event. Intensive Care Research, 1(3-4), pp.60-64.
What is the problem?
Even though sedation after endotracheal intubation (ETI) reduces the risk of self-extubation, uncontrolled pain, and awakening awareness, several small single-centre studies demonstrate low rates of sedative drug administration after ETI in the emergency department (ED). A retrospective cohort analysis of the ED portion of the National Hospital Ambulatory Medical Care Survey from 2006 to 2009 in the US revealed that less than one-half of patients undergoing ETI in the ED received sedative drugs while in the ED. A 2012 study on paediatric patients showed that approximately 42% were intubated without medications, and 2% were intubated with paralysis only in the ED.
What are the only exceptions?
Intubation in the immediate postnatal period for newborns with airway compromise.
When there is an immediate threat to life (e.g., in cardiac arrest where the time taken to site a line may lead to preventable neurological damage).
Awake fiberoptic intubation where the patient consents, co-operative AND the airway is prepared with local anaesthesia.
What are the potential physiological sequelae?
Regardless of the age, awake intubations can lead to tachycardia or bradycardia, raised blood pressure and low oxygen saturation. Studies showed that neonates who are intubated awake or with suxamethonium at induction may have raised intracranial pressure.
Using muscle relaxants alone in awake patients is also known to cause pulmonary oedema. This could be due to paralysis of the muscles which protect the upper airway.
In studies including patients with trauma or Glasgow Coma Scale less than 8, intubation without sedation led to poorer neurological outcomes.
In some patients, highly effective chest compressions may lead to regained consciousness. This is referred to as CPR Induced Consciousness (CPRIC). In this state, there are manifestations of consciousness, like eye-opening, limb/trunk movements, and speaking. While some studies showed that CPRIC is associated with increased survival to hospital discharge, administering muscle relaxants during resuscitation increased mortality.
When Ben was paralysed, he lost his respiratory drive while being fully aware of his surroundings. Unfortunately, in this case, the endotracheal tube was placed in the oesophagus, which meant he could not breathe independently.
What are the psychological sequelae?
According to the Royal College of Anaesthetists in the UK, accidental awareness during general anaesthesia can lead to the development of post-traumatic stress disorder. This is more common in patients who experienced paralysis alone or pain and paralysis together.
To be fully conscious, hypoxic and paralysed can only be described as a scene from a nightmare. Patients who have experienced awake intubations suffer from anxiety, nightmares, and preoccupation with death. In some cases, patients require psychiatric or psychological attention.
How can we prevent this?
A good understanding of the pharmacology of pre-intubation medications is a great place to start. An understanding of the mode and duration of action of these medications is equally important.
In some patients, we worry that administering sedation to haemodynamically unstable patients may worsen the blood pressure. While this is a genuine concern, it must not negate the very negative and dangerous complications of using paralytic medications without sedation for intubations.
For instance, if we are worried about cardiovascular stability, we can give appropriate vasoconstrictors like noradrenaline to prevent the expected vasodilation effects of sedation.
Education and re-education should be offered where this information or knowledge is lacking, whether in the pre-hospital or hospital settings. This may be in the form of audit projects, quality improvement projects, formal teachings and developing appropriate guidelines. Some centres have designed Local Safety Standards for Invasive Procedures (LocSSIPs) or Rapid Sequence Induction (RSI) checklists that can also help with safer intubation practices.
A never event
Never events are usually preventable serious adverse events which should be reported. This is followed by extensive analysis and development of preventive measures. Studies have shown the immediate and, in some cases, long-term psychological complications of paralysis only intubation. In our case, it led to a preventable death. This paralysis-only intubation meets the criteria for a never event.
Key take-home points
While Ben’s case is tragic, we can learn important points about airway management.
The Do-it-for-Drew Foundation has been set up in memory of Drew Hughes, a 13-year-old boy who died following a paralysis-only oesophageal intubation. This blog, like the paper cited, is dedicated to him.
References
Bano, Surraiya FCPS*; Akhtar, Saleem FCPSI†; Zia, Nukhba MBBS*; Khan, Uzma Rahim MBBS, MSc*; Haq, Anwar-ul MBBS, DABP, DABPCCM†. Pediatric Endotracheal Intubations for Airway Management in the Emergency Department. Pediatric Emergency Care 28(11): p 1129-1131, November 2012. | DOI: 10.1097/PEC.0b013e3182713316
Chong ID, Sandefur BJ, Rimmelin DE, Arbelaez C, Brown CA 3rd, Walls RM, Pallin DJ. 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. PMID: 24650718.
Hoffmann, Michael MD*; Czorlich, Patrick MD†; Lehmann, Wolfgang MD*; Spiro, Alexander S. MD*; Rueger, Johannes M. MD*; Lefering, Rolf PhD‡; on behalf of Trauma Register DGU of the German Trauma Society (DGU). The Impact of Prehospital Intubation with and Without Sedation on Outcome in Trauma Patients With a GCS of 8 or Less. Journal of Neurosurgical Anesthesiology 29(2): p 161-167, April 2017. | DOI: 10.1097/ANA.0000000000000275
https://patientsafetymovement.org/advocacy/patients-and-families/patient-stories/drew-hughes/
https://theresusroom.com/2018/11/30/paralysis-without-sedation-a-negligent-act/
Millar, C., Bissonnette, B. Awake intubation increases intracranial pressure without affecting cerebral blood flow velocity in infants. Can J Anaesth 41, 281–287 (1994). https://doi.org/10.1007/BF03009904
Pandit JJ, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O’Connor K, O’Sullivan EP, Paul RG, Palmer JH, Plaat F, Radcliffe JJ, Sury MR, Torevell HE, Wang M, Hainsworth J, Cook TM; Royal College of Anaesthetists; Association of Anaesthetists of Great Britain and Ireland. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth. 2014 Oct;113(4):549-59. doi: 10.1093/bja/aeu313. Epub 2014 Sep 9. PMID: 25204697.
Pappal RD, Roberts BW, Mohr NM, Ablordeppey E, Wessman BT, Drewry AM, Winkler W, Yan Y, Kollef MH, Avidan MS, Fuller BM. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness with Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021 May;77(5):532-544. doi: 10.1016/j.annemergmed.2020.10.012. Epub 2021 Jan 21. PMID: 33485698; PMCID: PMC8166299.
Weingart GS, Carlson JN, Callaway CW, Frank R, Wang HE. Estimates of sedation in patients undergoing endotracheal intubation in US EDs. Am J Emerg Med. 2013 Jan;31(1):222-6. doi: 10.1016/j.ajem.2012.05.015. PMID: 22770915.
