Abstract

Purpose/ Background:

Neuromuscular blocking agents (NMBAs) are commonly utilized in critically ill patients to facilitate endotracheal intubation and improve patient-ventilator synchrony. NMBAs do not possess intrinsic sedative, anxiolytic, or analgesic properties, necessitating adequate sedation prior to and throughout their use. Inadequate sedation may lead to awareness with paralysis (AWP), a complication associated with significant psychological morbidity. The Society of Critical Care Medicine & American College of Critical Care Medicine guidelines emphasize the need for deep sedation (Richmond Agitation-Sedation Scale [RASS] −4 to −5) prior to NMBA initiation and the use of objective monitoring such as Bispectral Index (BIS) titrated to 40-60 once paralysis is achieved. Despite these recommendations, adherence to sedation practices is variable, and no standardized measure exists within BHSF to assess compliance. This study aimed to evaluate the adequacy and timeliness of sedation practices in patients receiving NMBAs in critically ill patients.

Methodology:

This multi-center, retrospective, IRB-exempt, chart review included adult patients receiving continuous infusion paralytics for ≥ 2 hours in the ICU from November 2024-November 2025 across 7 hospitals within BHSF. Pregnant and incarcerated patients were excluded. The primary outcome was the number of patients receiving adequate sedation when receiving NMBA infusion, defined as either a documented RASS of -4 or -5 at the time of NMBA initiation or a documented BIS between 40 to 60 within 2 hours of NMBA initiation. Secondary outcomes included time to first documented BIS and the average time from NMBA initiation to first goal BIS.

Results:

A total of 110 patients were evaluated. Adequate sedation was achieved in 56% (n = 62) of patients, while 44% (n = 48) had inadequate sedation. At NMBA initiation, 38 patients had adequate RASS scores. BIS monitoring was obtained in 64% (n = 70) patients. Among those not meeting criteria based on adequate RASS, 24 achieved target BIS within 2 hours. Mean time to first goal BIS was approximately 9 hours. Of the 42 patients with documented BIS within 2 hours, 86% (n = 36) achieved goal BIS within 2 hours.

Conclusion:

Sedation practices in patients receiving NMBAs was inconsistent with 56% of patients meeting criteria for adequate sedation. BIS monitoring was commonly used however initiation was often delayed. Early BIS use was associated with a high rate of achieving goal sedation, identifying an opportunity for more timely and standardized sedation practices. These findings highlight the need for system-wide interventions, including alerts for NMBA orders to ensure adequate titration of sedation to goal BIS as well as ongoing education on deep sedation, timely BIS placement, consistent documentation, and reassessment after NMBA discontinuation.

Publication Date

Spring 5-15-2026

Presented At:

Florida Residency Conference 2026

Resident/Fellow

Jennifer Abrahante

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