Intubated, Awake, and Paralysed: A Never Event

Abstract

In this paper, we argue that paralysis-only intubation is almost never acceptable practice. We look at the evidence suggesting that this practice remains commonplace worldwide, its frequency has been exacerbated further by anaesthetic drug shortages secondary to the COVID-19 pandemic. We make a strong case that intubating a patient without sedation has such profound psychological and physiological risks that the practice is unethical and should be banned from medical practice with the exception of two clinical settings. These exceptions include (a) newborn intubation immediately after birth if there is immediate risk to life and (b) awake fibreoptic intubation whereby the patient has consented in advance, co-operative, and the airway has been prepared with local anaesthesia. We further argue that even in cases of cardiopulmonary resuscitation the practice impacts both on patient safety and clinician moral distress and as such in well-resourced times, there can be no justification for harming patients in this way. Formally labelling this practice as a Never Event is a way forward to homogeneously address the risks this archaic practice poses, both to our patients and to ourselves.

Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies*

“…Preventable mortality and serious morbidity from unrecognised oesophageal intubation continue to occur worldwide [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ], despite existing guideline recommendations and widely publicised education programmes [ 31 ] .…”

“…In the presence of high‐quality chest compressions, cardiac arrest cannot be assumed to be the cause of inability to satisfy the criteria for sustained exhaled carbon dioxide [ 99 ], and certainly does not explain a ‘flat trace’ ( https://youtu.be/t97G65bignQ ). Rather, failure to satisfy the criteria for sustained exhaled carbon dioxide in association with cardiac arrest should prompt exclusion of oesophageal intubation as its cause [ 11 , 13 , 14 , 15 , 16 , 18 , 21 , 23 , 29 , 30 ].…”

“…Preventable mortality and serious morbidity from unrecognised oesophageal intubation continue to occur worldwide [8–30], despite existing guideline recommendations and widely publicised education programmes [31] .…”

“…Occurrences may only be highlighted by coronial or media reports, and it is likely not all cases are reported. The number of these reports in recent years clearly indicates that preventable events occur regularly and are an international problem [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. In the 4th National Audit Project (NAP4) of the Royal College of Anaesthetists and Difficult Airway Society, nine cases of unrecognised oesophageal intubation were reported [ 42 , 43 ]: three during anaesthesia for surgery, four in the intensive care unit (ICU) and two in emergency departments.…”

Practice and Outcomes of Endotracheal Intubation in the Emergency Department : a retrospective observational study at a single institution in Bhutan

“…This practice of only paralytic intubation is never an acceptable practice and exponentially increases the risk of physiological complications and psychological sequalae; yet literature reveals the practice still persists today. (14,15,16) We reviewed the records and charts of these intubations and all patients had crash intubations and were placed on post intubation midazolam or ketamine infusion following return of spontaneous circulation(ROSC). This highlights the need of proper intubation guidelines and training in the department focusing on adequate analgesia and sedation to decrease the rate of this practice.…”