Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial.

Authors

Brian M Fuller
Brian E Driver
Michael B. Roberts, Philadelphia College of Osteopathic MedicineFollow
Christa A Schorr
Kathryn Thompson
Brett Faine
Julianne Yeary
Nicholas M Mohr
Ryan D Pappal
Robert J Stephens
Yan Yan
Nicholas J Johnson
Brian W Roberts

Document Type

Article

Publication Date

11-25-2023

Abstract

BACKGROUND: Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP.

METHODS: This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat.

DISCUSSION: The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care.

TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022.

Publication Title

Trials

Volume

24

Issue

1

PubMed ID

38001507

Comments

This article was published in Trials, Volume 24, Issue 1.

The published version is available at https://doi.org/10.1186/s13063-023-07764-5.

Copyright © 2023 The Author(s). CC BY 4.0.

Recommended Citation

Fuller, Brian M; Driver, Brian E; Roberts, Michael B.; Schorr, Christa A; Thompson, Kathryn; Faine, Brett; Yeary, Julianne; Mohr, Nicholas M; Pappal, Ryan D; Stephens, Robert J; Yan, Yan; Johnson, Nicholas J; and Roberts, Brian W, "Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial." (2023). PCOM Scholarly Works. 2238.
https://digitalcommons.pcom.edu/scholarly_papers/2238