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Meta-Analysis
. 2021 Mar 1;49(3):e304-e314.
doi: 10.1097/CCM.0000000000004824.

Awareness With Paralysis in Mechanically Ventilated Patients in the Emergency Department and ICU: A Systematic Review and Meta-Analysis

Ryan D Pappal  1 , Brian W Roberts  2 , Winston Winkler  1 , Lauren H Yaegar  3 , Robert J Stephens  4 , Brian M Fuller  4   5
Affiliations
Meta-Analysis

Awareness With Paralysis in Mechanically Ventilated Patients in the Emergency Department and ICU: A Systematic Review and Meta-Analysis

Ryan D Pappal et al. Crit Care Med. .

Abstract

Objective: Awareness with paralysis is a devastating complication for mechanically ventilated patients and can carry long-term psychologic sequelae. Hundreds of thousands of patients require mechanical ventilation in the emergency department and ICU annually, yet awareness has only been rigorously examined in the operating room (incidence ~0.1%). This report collates the global literature regarding the incidence of awareness with paralysis outside of the operating room.

Data sources: We searched OvidMedline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, conference proceedings, and reference lists.

Study selection: Randomized or nonrandomized studies (except single case studies) reporting on awareness with paralysis in the emergency department or ICU were eligible.

Data extraction: Two independent reviewers screened abstracts for eligibility.

Data synthesis: The search identified 4,454 potentially eligible studies. Seven studies (n = 941 patients) were included for analysis. A random effects meta-analysis of proportions along with multiple subgroup analyses was performed. Significant between-study heterogeneity in reporting of awareness with paralysis was noted, and the quality of the evidence was low. Analyses stratified by: 1) good-quality studies and 2) use of the modified Brice questionnaire to detect awareness revealed estimates of 3.4% (95% CI, 0-10.2%) and 1.9% (95% CI, 1.0-3.0%), respectively.

Conclusions: The incidence of awareness with paralysis in mechanically ventilated patients in the emergency department and ICU, as evaluated in a small number of qualifying studies from this comprehensive systematic review, appears much higher than that reported from the operating room. Given the clinical and statistical heterogeneity, caution is warranted in the interpretation of these findings. Further high-quality studies are needed to both define the true incidence and to target the prevention of awareness with paralysis in this vulnerable patient cohort.

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Conflict of interest statement

Mr. Pappal received funding from the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under Award Number TL1TR002344, Principal investigator: Jay F. Piccirillo, MD, FACS. Project Title: Washington University Institute of Clinical and Translational Sciences. Mr. Winkler was supported by the NIH T35 National Heart, Lung, and Blood Institute Training Grant, Grant Number 5T35HL007815, Principal investigator: Koong-Nah Chung, PhD. Dr. Fuller was supported by a grant-in-aid from the Division of Clinical and Translational Research of the Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Overall pooled meta-analysis of all studies, estimating the percent incidence of awareness with paralysis (see column “ES”). The vertical dashed line marks the overall effect size estimate. *PETAL Clinical Trials Network. AWP = awareness with paralysis. ES = effect size (i.e. percent incidence). CI = confidence interval.
Figure 2.
Figure 2.
Subgroup meta-analysis of all studies, stratified by quality (good vs. poor), estimating the percent incidence of awareness with paralysis (see column “ES”). Studies that only had a bias assessment were categorized as good quality if they were judged as low risk of bias and poor quality if they were judged as high risk of bias. The vertical dashed line marks the overall effect size estimate. AWP = awareness with paralysis. ES = effect size (i.e. percent incidence). CI = confidence interval.
Figure 3.
Figure 3.
Subgroup meta-analysis of all studies, stratified by survey instrument (modified Brice questionnaire vs. other), estimating the percent incidence of awareness with paralysis (see column “ES”). The vertical dashed line marks the overall effect size estimate. AWP = awareness with paralysis. ES = effect size (i.e. percent incidence). CI = confidence interval.
Figure 4.
Figure 4.
Subgroup meta-analysis of all studies, stratified by domain (ICU vs. ED), estimating the percent incidence of awareness with paralysis (see column “ES”). The vertical dashed line marks the overall effect size estimate. *PETAL Clinical Trials Network. AWP = awareness with paralysis. ES = effect size (i.e. percent incidence). CI = confidence interval. ICU = intensive care unit. ED = emergency department.
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Comment in

  • Mr. Sandman, Bring Me a Dream.
    Mohr NM, Sharma A. Mohr NM, et al. Crit Care Med. 2021 Mar 1;49(3):540-544. doi: 10.1097/CCM.0000000000004880. Crit Care Med. 2021. PMID: 33616356 No abstract available.

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