Background: Rapid-sequence intubation (RSI) involves administration of an induction agent and neuromuscular blocking agent to facilitate patient comfort and endotracheal intubation. Following RSI, initiation of post-intubation sedation is essential to maintain patient comfort, reduce agitation, and prevent awareness with paralysis (AWP), which has been associated with psychological distress and other adverse outcomes. Several factors may contribute to AWP, including the use of long-acting neuromuscular blocking agents such as rocuronium, underdosing of induction agents, and delays in initiation of post-intubation sedation. In many emergency department (ED) settings, post-intubation sedation may be delayed, inconsistently initiated, or omitted, potentially increasing the risk of “awake paralysis.” At our community hospital, pharmacists are not routinely involved in the RSI process, as medication orders are auto-verified and pharmacy staff are not alerted when intubations occur. Additionally, the existing RSI order set does not include guidance for post-intubation sedation. Pharmacists may play an important role in supporting medication selection, preparation, and timely initiation of sedation following RSI. The purpose of this study was to evaluate to evaluate post-intubation sedation practices following RSI in the ED at a community hospital.
Methodology: This single-center, IRB-reviewed, determined exempt retrospective evaluation assessed adult patients undergoing RSI in the ED between January 2025 and March 2025. Adult patients aged ≥ 18 years who underwent RSI with an induction agent and neuromuscular blocking agent in the ED were included. Patients were excluded if intubation or post-intubation management was performed by a non-ED provider, RSI occurred outside the ED, the patient died in the ED, or ED length of care was less than one hour. Outcomes evaluated included receipt of a sedative within one hour following RSI and time to first sedative administration. Continuous variables were summarized using descriptive statistics, and categorical variables were reported as frequencies and percentages.
Results: A total of 186 patients were screened, of which 52 patients met inclusion criteria for evaluation. The mean age was 65 years (SD 13.3), and 54% were female. The most common indication for RSI was respiratory distress (58%), followed by altered mental status (21%) and unresponsiveness (13%). Etomidate was the most commonly used induction agent (79%), and rocuronium was the most frequently used neuromuscular blocking agent (77%). Overall, 81% of patients received at least one sedative agent within one hour following RSI. Fentanyl was the most commonly used agent (88%), while propofol was the second most frequently used sedative (63%), followed by midazolam (21%). The mean time to first sedative dose was 29.4 minutes.
Conclusion: In this evaluation of post-intubation sedation practices following RSI in the ED, most patients received a sedative within one hour; however, variability in the timing and initiation of therapy was observed. Delays or absence of sedation following RSI may increase the risk of complications such as inadequate sedation and awareness with paralysis. These findings highlight an opportunity to improve the consistency and timeliness of post-intubation sedation practices. Greater pharmacist involvement during RSI events may help optimize medication selection and promote more timely initiation of sedation. Future efforts should focus on establishing a consistent pharmacy presence in the ED and developing a standardized workflow to facilitate pharmacist involvement during RSI events.
