Intubated, Awake, and Paralysed: A Never Event

Abstract

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.

Keywords

• Intubation
• paralysis only intubation
• awareness during resuscitation
• awareness during intubation
• awareness during CPR
• awareness during anaesthesia