Impact of an Emergency Medicine Pharmacist on Post-Rapid Sequence Intubation Sedation

Introduction: Rapid sequence intubation (RSI) involves sedatives, paralytics, and analgesics. Proper sedation before and after RSI is critical to prevent awareness with paralysis (AWP), especially since paralytics mask patient responses. Emergency medicine pharmacists are well positioned to help with analgesic and sedative choice, dosing and administration post RSI in the emergency department. Literature has shown pharmacist involvement reduces time to post-intubation sedation and increases rates of post-intubation analgesia administration. The purpose of this study was to evaluate pharmacist impact on sedation and analgesia practices post RSI with paralytics.


Methods: This retrospective study reviewed patients ≥18 years old who underwent RSI with paralytic in the Pennsylvania Hospital emergency department. Exclusion criteria included cardiac arrest, pre-hospital intubation, no paralytics administered, or incomplete sedation/paralytic documentation.
The primary outcome was time from paralytic administration to sedation. Secondary outcomes included propofol-associated hypotension, sedation dosing differences, proportion of patients started on analgesia, and time to analgesia administration.


Results: Of 120 patients screened, 93 met inclusion (21 with pharmacist involvement, 72 without). The median age was 62, and most were male, admitted for medical, non-trauma conditions. Etomidate (88%) and rocuronium (71%) were the primary agents used. Median time to sedation was significantly shorter with a pharmacist involved (8 min vs. 17 min, p < 0.001). Of 82 patients who received propofol, infusion rates were higher in the pharmacist group (p < 0.001), promoting deeper sedation. Hypotension rates were similar between groups (p > 0.05). Analgesia was administered in 45.2% of all cases. Median time to analgesia was 72 min in the pharmacist group vs. 43 min in the non-pharmacist group (p = 0.38).


Conclusions: Pharmacist involvement in RSI was associated with faster sedation and higher sedative doses, without increasing hypotension risk. Delayed analgesia administration was likely due to prioritizing sedation to prevent AWP in a non-trauma population. These results support the pharmacist’s role in optimizing post-RSI care.