{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T02:29:51Z","timestamp":1785464991619,"version":"3.56.0"},"reference-count":43,"publisher":"Oxford University Press (OUP)","issue":"17","license":[{"start":{"date-parts":[[2025,3,22]],"date-time":"2025-03-22T00:00:00Z","timestamp":1742601600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,8,19]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Purpose<\/jats:title>\n                  <jats:p>Awareness with paralysis (AWP) is an increasingly recognized complication of neuromuscular blocker use and is associated with adverse patient experiences. This manuscript describes the incidence of AWP and mitigation strategies that can be employed to prevent its occurrence and ensure optimal patient care.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Summary<\/jats:title>\n                  <jats:p>Preventative strategies are essential to reduce the incidence of AWP. Approaches for prevention include awareness of the duration of action of analgesics, sedatives, and neuromuscular blocking agents (NMBAs), timely administration of postprocedural sedation, use of NMBAs for the shortest duration possible, and monitoring of the depth of sedation and neuromuscular blockade. Pharmacists are integral members of the multidisciplinary team in the emergency department and intensive care unit, where nonoperative neuromuscular blocker use is most common. Pharmacists can play a key role in eliminating AWP through their knowledge of the pharmacokinetics and pharmacodynamics of sedatives and NMBAs and their role in medication selection and monitoring.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>By applying key strategies to prevent AWP, pharmacists can help make AWP a never event in both procedural and continuous use of NMBAs.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/ajhp\/zxaf072","type":"journal-article","created":{"date-parts":[[2025,3,23]],"date-time":"2025-03-23T07:18:14Z","timestamp":1742714294000},"page":"e736-e742","source":"Crossref","is-referenced-by-count":6,"title":["Strategies to prevent awareness with paralysis following administration of neuromuscular blocking agents"],"prefix":"10.1093","volume":"82","author":[{"given":"Dustin D","family":"Linn","sequence":"first","affiliation":[{"name":"Philips North America, Cambridge, MA, and Department of Pharmacy, Parkview Health , Fort Wayne, IN ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Megan A","family":"Rech","sequence":"additional","affiliation":[{"name":"Department of Veterans Affairs, Center of Innovation for Complex Chronic Care, Edward Hines, Jr. VA Hospital , Hines, IL ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brett A","family":"Faine","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine and Pharmacy, University of Iowa Hospitals and Clinics , Iowa City, IA ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2025,3,22]]},"reference":[{"issue":"5","key":"2025081819562186200_CIT0001","doi-asserted-by":"publisher","first-page":"532","DOI":"10.1016\/j.annemergmed.2020.10.012","article-title":"The ED-AWARENESS study: a prospective, observational cohort study of awareness with paralysis in mechanically ventilated patients admitted from the emergency department","volume":"77","author":"Pappal","year":"2021","journal-title":"Ann Emerg Med"},{"key":"2025081819562186200_CIT0002","doi-asserted-by":"publisher","first-page":"19","DOI":"10.1016\/j.ajem.2023.05.004","article-title":"Pharmacotherapy optimization for rapid sequence intubation in the emergency department","volume":"70","author":"Engstrom","year":"2023","journal-title":"Am J Emerg Med."},{"issue":"2","key":"2025081819562186200_CIT0003","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1002\/j.1875-9114.1998.tb03862.x","article-title":"Patient recall of therapeutic paralysis in a surgical critical care unit","volume":"18","author":"Wagner","year":"1998","journal-title":"Pharmacotherapy"},{"issue":"3","key":"2025081819562186200_CIT0004","doi-asserted-by":"publisher","first-page":"823","DOI":"10.1213\/ANE.0b013e3181b8b6ca","article-title":"Posttraumatic stress disorder in aware patients from the B-Aware trial","volume":"110","author":"Leslie","year":"2010","journal-title":"Anesth Analg"},{"issue":"3","key":"2025081819562186200_CIT0005","doi-asserted-by":"publisher","first-page":"833","DOI":"10.1213\/01.ANE.0000130261.90896.6C","article-title":"The incidence of awareness during anesthesia: a multicenter United States study","volume":"99","author":"Sebel","year":"2004","journal-title":"Anesth Analg"},{"issue":"9205","key":"2025081819562186200_CIT0006","doi-asserted-by":"publisher","first-page":"707","DOI":"10.1016\/S0140-6736(99)11010-9","article-title":"Awareness during anaesthesia: a prospective case study","volume":"355","author":"Sandin","year":"2000","journal-title":"Lancet"},{"issue":"3","key":"2025081819562186200_CIT0007","doi-asserted-by":"publisher","first-page":"e304","DOI":"10.1097\/CCM.0000000000004824","article-title":"Awareness with paralysis in mechanically ventilated patients in the emergency department and ICU: a systematic review and meta-analysis","volume":"49","author":"Pappal","year":"2021","journal-title":"Crit Care Med"},{"issue":"5","key":"2025081819562186200_CIT0008","doi-asserted-by":"publisher","first-page":"1072","DOI":"10.1097\/00000539-199611000-00030","article-title":"A comparison of cisatracurium and atracurium: onset of neuromuscular block after bolus injection and recovery after subsequent infusion","volume":"83","author":"Mellinghoff","year":"1996","journal-title":"Anesth Analg"},{"issue":"4","key":"2025081819562186200_CIT0009","doi-asserted-by":"publisher","first-page":"1267","DOI":"10.1378\/chest.126.4.1267","article-title":"A prospective randomized comparison of train-of-four monitoring and clinical assessment during continuous ICU cisatracurium paralysis","volume":"126","author":"Baumann","year":"2004","journal-title":"Chest"},{"key":"2025081819562186200_CIT0010","author":"Cisatracurium besylate injection, solution","year":"2024"},{"issue":"5","key":"2025081819562186200_CIT0011","doi-asserted-by":"publisher","first-page":"913","DOI":"10.1097\/00000542-199311000-00007","article-title":"Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of anesthesia in adult patients","volume":"79","author":"Magorian","year":"1993","journal-title":"Anesthesiology"},{"issue":"7","key":"2025081819562186200_CIT0012","doi-asserted-by":"publisher","first-page":"811","DOI":"10.1111\/aas.14097","article-title":"Rocuronium 0.3 or 0.9\u00a0mg\/kg comparing onset time, duration of action, and intubating conditions in patients 80\u2009years and older: a randomized study","volume":"66","author":"Vested","year":"2022","journal-title":"Acta Anaesthesiol Scand"},{"issue":"3","key":"2025081819562186200_CIT0013","doi-asserted-by":"publisher","first-page":"667","DOI":"10.1097\/00000539-199709000-00033","article-title":"Dose-response and time course of effect of rocuronium in male and female anesthetized patients","volume":"85","author":"Xue","year":"1997","journal-title":"Anesth Analg"},{"issue":"10","key":"2025081819562186200_CIT0014","doi-asserted-by":"publisher","first-page":"1449","DOI":"10.1097\/CCM.0000000000005626","article-title":"Awareness with paralysis among critically ill emergency department patients: a prospective cohort study","volume":"50","author":"Fuller","year":"2022","journal-title":"Crit Care Med"},{"issue":"2","key":"2025081819562186200_CIT0015","doi-asserted-by":"publisher","first-page":"313","DOI":"10.1016\/j.chest.2022.08.2232","article-title":"Recall of awareness during paralysis among ED patients undergoing tracheal intubation","volume":"163","author":"Driver","year":"2023","journal-title":"Chest"},{"issue":"2","key":"2025081819562186200_CIT0016","doi-asserted-by":"publisher","first-page":"227","DOI":"10.1016\/j.ccell.2006.02.001","article-title":"Impact of bispectral index monitoring on sedation and outcomes in critically ill adults: a case series","volume":"18","author":"Arbour","year":"2006","journal-title":"Crit Care Nurs Clin North Am"},{"issue":"5","key":"2025081819562186200_CIT0017","doi-asserted-by":"publisher","first-page":"545","DOI":"10.1016\/j.annemergmed.2020.11.006","article-title":"Speechless: awareness with recall of paralysis in the emergency department setting","volume":"77","author":"Gottlieb","year":"2021","journal-title":"Ann Emerg Med"},{"issue":"2","key":"2025081819562186200_CIT0018","doi-asserted-by":"publisher","first-page":"336","DOI":"10.1097\/ALN.0000000000004808","article-title":"Awake total neuromuscular blockade as experienced by anesthesiologist volunteers","volume":"140","author":"Schuller","year":"2024","journal-title":"Anesthesiology"},{"issue":"10","key":"2025081819562186200_CIT0019","doi-asserted-by":"publisher","first-page":"1411","DOI":"10.1097\/CCM.0000000000006000","article-title":"Society of Critical Care Medicine clinical practice guidelines for rapid sequence intubation in the critically ill adult patient","volume":"51","author":"Acquisto","year":"2023","journal-title":"Crit Care Med"},{"issue":"3","key":"2025081819562186200_CIT0020","doi-asserted-by":"publisher","first-page":"219","DOI":"10.1016\/j.jemermed.2004.04.008","article-title":"Errors in weight estimation in the emergency department: comparing performance by providers and patients","volume":"27","author":"Hall","year":"2004","journal-title":"J Emerg Med"},{"issue":"12","key":"2025081819562186200_CIT0021","doi-asserted-by":"publisher","first-page":"2423","DOI":"10.1016\/j.ajem.2016.09.056","article-title":"Accuracy of rapid sequence intubation medication dosing in obese patients intubated in the ED","volume":"34","author":"Bhat","year":"2016","journal-title":"Am J Emerg Med"},{"issue":"3","key":"2025081819562186200_CIT0022","doi-asserted-by":"publisher","first-page":"206","DOI":"10.1097\/MEJ.0b013e3283606b89","article-title":"Comparison of rocuronium and succinylcholine on postintubation sedative and analgesic dosing in the emergency department","volume":"21","author":"Korinek","year":"2014","journal-title":"Eur J Emerg Med"},{"issue":"11","key":"2025081819562186200_CIT0023","doi-asserted-by":"publisher","first-page":"893","DOI":"10.1136\/emermed-2012-201812","article-title":"Effect of paralytic type on time to post-intubation sedative use in the emergency department","volume":"30","author":"Watt","year":"2013","journal-title":"Emerg Med J"},{"issue":"1","key":"2025081819562186200_CIT0024","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1097\/ALN.0000000000004379","article-title":"2023 American Society of Anesthesiologists practice guidelines for monitoring and antagonism of neuromuscular blockade: a report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade","volume":"138","author":"Thilen","year":"2023","journal-title":"Anesthesiology"},{"issue":"1","key":"2025081819562186200_CIT0025","doi-asserted-by":"publisher","first-page":"897","DOI":"10.1038\/s41598-022-04818-7","article-title":"A retrospective study of sugammadex for reversal of neuromuscular blockade induced by rocuronium in critically ill patients in the ICU","volume":"12","author":"Bologheanu","year":"2022","journal-title":"Sci Rep"},{"issue":"4","key":"2025081819562186200_CIT0026","doi-asserted-by":"publisher","first-page":"880","DOI":"10.1177\/08971900231194564","article-title":"Neurologic examination facilitated by reversal of rocuronium with sugammadex","volume":"37","author":"Falksen","year":"2024","journal-title":"J Pharm Pract"},{"issue":"7","key":"2025081819562186200_CIT0027","doi-asserted-by":"publisher","first-page":"713","DOI":"10.1111\/acem.14856","article-title":"Emergency department usage of sugammadex in a large regional health system","volume":"31","author":"Jansson","year":"2024","journal-title":"Acad Emerg Med"},{"issue":"10","key":"2025081819562186200_CIT0028","doi-asserted-by":"publisher","first-page":"e30466","DOI":"10.7759\/cureus.30466","article-title":"Sugammadex to facilitate neurologic assessment in severely brain-injured patients: a retrospective analysis and practical guidance","volume":"14","author":"Hyland","year":"2022","journal-title":"Cureus"},{"issue":"3","key":"2025081819562186200_CIT0029","doi-asserted-by":"crossref","first-page":"139","DOI":"10.4037\/ajcc2001.10.3.139","article-title":"A national survey of critical care nurses\u2019 practices related to administration of neuromuscular blocking agents","volume":"10","author":"Foster","year":"2001","journal-title":"Am J Crit Care"},{"issue":"4","key":"2025081819562186200_CIT0030","doi-asserted-by":"publisher","first-page":"413","DOI":"10.1097\/00000542-197210000-00011","article-title":"The relation between the response to \u201ctrain-of-four\u201d stimulation and receptor occlusion during competitive neuromuscular block","volume":"37","author":"Waud","year":"1972","journal-title":"Anesthesiology"},{"issue":"11","key":"2025081819562186200_CIT0031","doi-asserted-by":"publisher","first-page":"2079","DOI":"10.1097\/CCM.0000000000002027","article-title":"Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient","volume":"44","author":"Murray","year":"2016","journal-title":"Crit Care Med"},{"issue":"21","key":"2025081819562186200_CIT0032","doi-asserted-by":"publisher","first-page":"1997","DOI":"10.1056\/NEJMoa1901686","article-title":"Early neuromuscular blockade in the acute respiratory distress syndrome","volume":"380","author":"Moss","year":"2019","journal-title":"N Engl J Med"},{"issue":"9","key":"2025081819562186200_CIT0033","doi-asserted-by":"publisher","first-page":"e825","DOI":"10.1097\/CCM.0000000000003299","article-title":"Clinical practice guidelines for the prevention and management of pain, agitation\/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU","volume":"46","author":"Devlin","year":"2018","journal-title":"Crit Care Med"},{"issue":"9","key":"2025081819562186200_CIT0034","doi-asserted-by":"publisher","first-page":"CD003843","DOI":"10.1002\/14651858.CD003843.pub4","article-title":"Bispectral index for improving intraoperative awareness and early postoperative recovery in adults","volume":"9","author":"Lewis","year":"2019","journal-title":"Cochrane Database Syst Rev"},{"issue":"8","key":"2025081819562186200_CIT0035","doi-asserted-by":"publisher","first-page":"667","DOI":"10.1002\/phar.2712","article-title":"Systematic review and meta-analysis of the correlation between bispectral index (BIS) and clinical sedation scales: toward defining the role of BIS in critically ill patients","volume":"42","author":"Heavner","year":"2022","journal-title":"Pharmacotherapy"},{"issue":"1","key":"2025081819562186200_CIT0036","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1097\/00000542-200307000-00006","article-title":"Overestimation of bispectral index in sedated intensive care unit patients revealed by administration of muscle relaxant","volume":"99","author":"Vivien","year":"2003","journal-title":"Anesthesiology"},{"issue":"2","key":"2025081819562186200_CIT0037","doi-asserted-by":"publisher","first-page":"271","DOI":"10.1177\/08971900221131420","article-title":"A comparison of midazolam and propofol for deep sedation in patients with acute respiratory distress syndrome requiring neuromuscular blocking agents","volume":"37","author":"Addison","year":"2024","journal-title":"J Pharm Pract"},{"key":"2025081819562186200_CIT0038","doi-asserted-by":"publisher","first-page":"9853344","DOI":"10.1155\/2022\/9853344","article-title":"Ketamine infusion for sedation and analgesia during mechanical ventilation in the ICU: a multicenter evaluation","volume":"2022","author":"Pendleton","year":"2022","journal-title":"Crit Care Res Pract"},{"issue":"1","key":"2025081819562186200_CIT0039","doi-asserted-by":"publisher","first-page":"263","DOI":"10.1097\/CCM.0b013e3182783b72","article-title":"Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit","volume":"41","author":"Barr","year":"2013","journal-title":"Crit Care Med"},{"issue":"4","key":"2025081819562186200_CIT0040","doi-asserted-by":"publisher","first-page":"365","DOI":"10.1056\/NEJMra1800222","article-title":"Opioid tolerance in critical illness","volume":"380","author":"Martyn","year":"2019","journal-title":"N Engl J Med"},{"issue":"11","key":"2025081819562186200_CIT0041","doi-asserted-by":"publisher","first-page":"1977","DOI":"10.1007\/s00134-020-06227-8","article-title":"Neuromuscular blockade in patients with ARDS: a rapid practice guideline","volume":"46","author":"Alhazzani","year":"2020","journal-title":"Intensive Care Med"},{"issue":"17","key":"2025081819562186200_CIT0042","doi-asserted-by":"publisher","first-page":"1513","DOI":"10.2146\/ajhp120673","article-title":"Effect of a pharmacist on timing of postintubation sedative and analgesic use in trauma resuscitations","volume":"70","author":"Amini","year":"2013","journal-title":"Am J Health-Syst Pharm"},{"issue":"3","key":"2025081819562186200_CIT0043","doi-asserted-by":"publisher","first-page":"100089","DOI":"10.1016\/j.chstcc.2024.100089","article-title":"Mind the gap: estimated duration of inadequate sedation following rapid sequence induction and intubation in critically ill patients","volume":"2","author":"Mangaoang","year":"2024","journal-title":"CHEST Crit Care."}],"container-title":["American Journal of Health-System Pharmacy"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/ajhp\/advance-article-pdf\/doi\/10.1093\/ajhp\/zxaf072\/62523142\/zxaf072.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ajhp\/article-pdf\/82\/17\/e736\/62523142\/zxaf072.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ajhp\/article-pdf\/82\/17\/e736\/62523142\/zxaf072.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,18]],"date-time":"2025-08-18T23:56:30Z","timestamp":1755561390000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ajhp\/article\/82\/17\/e736\/8090339"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,3,22]]},"references-count":43,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2025,3,22]]},"published-print":{"date-parts":[[2025,8,19]]}},"URL":"https:\/\/doi.org\/10.1093\/ajhp\/zxaf072","relation":{},"ISSN":["1079-2082","1535-2900"],"issn-type":[{"value":"1079-2082","type":"print"},{"value":"1535-2900","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2025,9,1]]},"published":{"date-parts":[[2025,3,22]]}}}