Impact of Paralytic Choice on Post-Intubation Sedation Practices

Timely initiation of adequate sedation and analgesia following administration of a paralytic agent for rapid sequence intubation (RSI) is essential to prevent awareness with paralysis (AWP). Prior observational studies show an incidence of AWP in 2.6-3.4% of patients after mechanical ventilation in the emergency department (ED). Delays in sedation and analgesia may result in increased psychological distress and adverse physiological responses. The objective of this study was to assess sedation prescribing practices after RSI in the ED to determine if paralytic choice impacts time to sedation initiation.

This single-center, retrospective chart review conducted in a community hospital included adult patients who received a paralytic for RSI in the ED between January 1, 2023 and October 1, 2025. Patients were excluded if they were intubated prior to hospital arrival or via a tracheostomy stoma. Data were collected for 100 randomly selected patients, equally divided between rocuronium and succinylcholine. The primary endpoint assessed time from paralytic administration to initiation of post-intubation sedation. Secondary endpoints include the selection of a sedative versus analgesic agent as the initial post-intubation management agent, depth of sedation while in the ED using the Richmond Agitation and Sedation Scale (RASS), and time to first sedation and pain assessment using the RASS and Critical Care Pain Observation Tool (CPOT). Data were analyzed using student's t-test, likelihood ratio test, chi-square, and Fisher's exact test.

There were no observed differences between groups for any baseline demographics, including reason for intubation and primary or secondary endpoints. Time to sedation administration was 16.96 minutes in the rocuronium group and 12.51 minutes in the succinylcholine group (p = 0.56). Analgesia was administered to 32% of patients in the rocuronium group and 36% in the succinylcholine group while in the ED. Initial RASS and CPOT scores were recorded in the ICU for approximately 80% of patients.

Time to post-intubation sedation did not differ statistically between paralytic agents, though it was numerically longer in the rocuronium group, which may be clinically significant. Analgesic use and assessment of pain and sedation depth while in the ED were infrequent in both groups, highlighting opportunities for practice improvement.