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

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ID: 316508
2026
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Ranked #116 of 143 articles by views in American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists

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Abstract
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.
Reference Key
openalex_W7164011787 Use this key to autocite in the manuscript while using SciMatic Manuscript Manager or Thesis Manager
Authors Madison Fielding, Akhil Khosla, Mahmoud Ammar, Richard Chung, Alex Aliling, Thomas Warzecha, Jennifer Johnson, Albert Zichichi
Journal American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists
Year 2026
DOI
10.1093/ajhp/zxag170
URL
https://doi.org/10.1093/ajhp/zxag170
Keywords Keywords not found

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