Leveraging clinical decision support to minimize sedation gaps in patients receiving rocuronium for rapid sequence intubation

PURPOSE: Rapid sequence intubation (RSI) with neuromuscular blocking agents (NMBAs) can result in awareness with paralysis (AWP) if sedation is inadequate. This is of particular concern with rocuronium due to its prolonged half-life. This study evaluated sedation practices before and after the implementation of an RSI clinical decision support (CDS) update with sedation guidance linked to rocuronium orders. METHODS: This retrospective, multicenter, observational, before-after study included adult patients who received rocuronium for RSI. The preimplementation cohort spanned the period July 1, 2022, to January 1, 2023; the postimplementation cohort spanned the period January 1 to July 1, 2024. Coprimary outcomes were sedative selection and initial sedative dose within 1 hour after rocuronium administration. Secondary outcomes included time to sedative initiation, time to adequate sedation, and incidence of hypotension requiring vasopressors. Groups were compared using a t test or Mann-Whitney U test for continuous variables and χ2 or Fisher's exact test for categorical variables. RESULTS: A total of 713 patients were included (308 in the preimplementation and 405 in the postimplementation cohort). After CDS implementation, propofol use increased (56.8% vs 73.1%, P < 0.0001), and initial dosing increased (median, 5 µg/kg/min vs 20 µg/kg/min; P < 0.0001). Midazolam use decreased (from 32.1% to 19.3%, P < 0.0001). The median (interquartile range IQR) time to sedation initiation decreased (from 14 10-22 minutes to 12 12-15 minutes; P = 0.001), as did median time to adequate sedation (from 32 15.3-51.4 minutes to 14 12-25 minutes; P < 0.0001). The incidence of new-onset hypotension was similar between groups (25.0% vs 25.2%, P = 0.95). CONCLUSION: A CDS update linking sedation guidance to rocuronium orders resulted in faster initiation of higher doses of sedation after paralysis without increasing hemodynamic instability, supporting the use of CDS strategies in the peri-intubation period.