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Adventures in RSI

Pediatric airway management is a skill that integrates the three types of knowledge as described by the ancient Greeks:

Episteme — theoretical knowledge

Techne — technical knowledge

Phronesis — practical wisdom — also called prudence.

Here we’ll invoke each type of knowledge and understanding as we go beyond the anatomical issues in pediatric airway management – to the advanced decision-making aspect of RSI and the what-to-do-when the rubber-hits-the road.


Case 1: Sepsis

Laura is a 2-month-old baby girl born at 32 weeks gestational age who today has been “breathing fast” per mother.  On arrival she is in severe respiratory distress with nasal flaring and intercostal retractions.   Her heart rate is 160, RR 50, oxygen saturation is 88% on RA.  She has fine tissue-paper like rales throughout her lung fields.  Despite a trial of a bronchodilator, supplemental oxygen, even nasal CPAP and fluids, she becomes less responsive and her heart rate begins to drop relatively in the 80s to 90s – this is not a sign of improvement, but of impending cardiovascular collapse.

She is in respiratory failure from bronchiolitis and likely viral sepsis.  She needs her airway taken over.

Is this child stable enough for intubation?

We have a few minutes to optimize, to resuscitate before we intubate.

Here’s an easy tip: use the sterile flushes in your IV cart and push in 20, 40, or 60 mL/kg NS.  Just keep track of the number of syringes you use – it is the fastest way to get a meaningful bolus in a small child.

Alternatively, if you put a 3-way stop-cock in the IV line and attach a 30 mL syringe, you can turn the stop cock, draw up stream from the IV bag into the syringe, turn te stop cock, and push the fluid in the IV.

Induction Agent in Sepsis

The consensus recommendation for the induction agent of choice for sepsis in children is ketamine.

Etomidate is perfectly acceptable, but ketamine is actually a superior drug to etomidate in the rapid sequence intubation of children in septic shock.  It rapidly provides sedation and analgesia, and supports hemodynamic stability by blocking the reuptake of catecholamines.

Paralytic Agent in Sepsis

The succinylcholine versus rocuronium debate…

Succinylcholine and its PROS

Succinylcholine and its CONs

  • Raises serum potassium in everyone, typically 0.5 to 1 mEq/L.  That is not usually a problem, but for those with preexisting or inducible hyperkalemia, it can precipitate an arrest, as in renal failure, underlying neurologic or myopathic conditions like multiple sclerosis, muscular dystrophy, ALS, or those who had a stroke or a burn more than 72 hours prior. We often have limited information in critical situations.
  • Succinylcholine gives us a false sense of security.  In children, there really is no “safe apnea” period.
  • Succinylcholine’s effect on the nicotinic receptors results in mydriasis, tachycardia, weakness, twitching and hypertension, and fasciculations (Think nicotine overdose: M/T/W/Th/F).
  • Succinylcholine’s effect on muscarinic receptors manifest (as in organophosphate overdose): SLUDGE – salivation, lacrimation, urination, defecation, GI upset or more apropos here: DUMBBELLS – diarrhea, urination, miosis, bradycardia, emesis, lacrimation, lethargy, salivation.
  • Second dose of succinylcholine – beware of the muscarinic effects and bradycardia. Co-administer atropine, 0.01 mg/kg, up to 0.5 mg IV.

Coda: succinylcholine is not that bad – we would not have had such great success with it during the early years of our specialty if it were such a terrible drug.  The side effects are rare, but they can be deadly.  So, what’s the alternative?

Rocuronium and its PROs

  • It has none of the side-effects of succinylcholine

Rocuronium and its CONs

  • Argument 1: the duration is too long if there is a difficult airway, since rocuronium can last over an hour.
    Still need to intubate, and now your patient is potentially worse.
  • Argument 2: succinylcholine produces better intubating conditions at 45 seconds compared to rocuronium.
    At 0.6 mg/kg, rocuronium is inferior to succinylcholine at all time intervals. At 1.0 mg/kg, rocuronium is still inferior at 45 seconds.  1.2 mg/kg rocuronium is the dose now commonly recommended; per a study by Heier et al. in Anesthesia and Analgesia in 2000, rocuronium produced excellent intubating conditions in higher doses.

Case 2: Multitrauma

Joseph is a 3-year-old boy who is excited that there are so many guests at his home for a family party and when it’s starting to wind down and the guests begin to leave, he is unaccounted for.  An unsuspecting driver of a mini-van backs over him.

He is brought in by paramedics, who are now bagging him.

Induction Agent in Trauma

  • Need something that is hemodynamically stable – agents such as midazolam or propofol would cause too many problems.
  • Etomidate is a short-acting imidazole derivative that acts on GABA-A receptors to induce loss of consciousness in 5-15 seconds. It can cause apnea, pain on injection, and myoclonus.
  • Etomidate reduces cerebral blood flow, reduces intracranial pressure, and reduces cerebral oxygen consumption, all while maintaining arterial blood pressure and cerebral perfusion pressure.
  • Ketamine is reasonable as well: there is no contraindication to ketamine except for known hydrocephalus. It is safe in head trauma.  It is a good choice for the hypotensive trauma patient.  TBI is not a contraindication.
  • In the case of the critically injured child who is normotensive, ketamine will raise his blood pressure and perhaps foster further bleedingThe goal is a good general perfusion and a balanced resuscitation, ensuring enough cerebral perfusion without disrupting nascent clots.  On the other side of the spectrum, permissive hypotension is not described in children, as hypotension is a late and dangerous sign of shock.

Paralytic Agent in Trauma

Are your surgeons in an uproar about a long-acting agent and the pupillary response?  Relax, it’s a myth.

Caro et al. in Annals of Emergency Medicine in 2011 reported that the majority of patients undergoing RSI preserved their pupillary response.  Succinylcholine actually performed worse than rocuronium.  In the rocuronium group, all patients preserved their pupillary response.

In the critically ill, rethink your dosing of both the sedative and the paralytic.

In a critically ill child or adult, perfusion suffers and it affects how we administer medications.  The patient’s arm-brain time or vein-to-brain time is less efficient; additionally, as the patient’s hemodynamic status softens, he becomes very sensitive to the effects of sedatives.

We need to adjust our dosing for a critically ill patient:

Decrease the sedative to avoid falling over the hemodynamic compensation cliff.

Increase the paralytic to account for prolonged arm-brain time.


Case 3: Cardiac/myocarditis/congenital heart disease

Jacob is a 6-year-old-boy with tricuspid atresia s/p Fontan procedure who’s had one week of runny nose, cough, and now 2 days of high fever, vomiting, and difficulty breathing.

The Fontan procedure is the last in a series of three palliative procedures in a child with complex cyanotic congenital heart disease with a single-ventricle physiology.

The procedure reroutes venous blood to flow passively into the pulmonary arteries, because the right ventricle has been surgically repurposed to be the systemic pump.  The other most common defect with an indication for a Fontan is hypoplastic left heart syndrome.

Typical “normal” saturations for post-operative CHD can be 75 and 85% on RA.  The Fontan procedure improves saturations, which are typically 88-95%.  Ask the parents or caregiver.

Complications of the Fontan procedure include heart failure, superior vena cava syndrome, hypercoagulable state, and others.
A patient with a Fontan can present in cardiogenic shock from heart failure, distributive shock from an increased risk of infection, hypovolemic shock from over-diuresis or insensible fluid loss – or just a functional hypovolemia from the fact that his venous return is all passive – and finally obstructive shock due to a pulmonary thromboembolism.

Types of shock: this is how people COHDeCardiogenic, Obstructive, Hypovolemic, Distributive.

Do we give fluids?

Children after palliative surgery for cyanotic heart disease are volume-dependent.  Even if there is a component of cardiogenic shock, they need volume to drive their circuit.  Give a test dose of 10 mL/kg NS.

Pressors in Pediatric Shock

  • Children compensate their shock state early by increasing their SVR.
  • Epinephrine (adrenaline) is great at increasing the cardiac output (with minimal increase in systemic vascular resistance; tachycardia)  In children the cardiac deleterious effects are not pronounced as in adults.  Later when the child is stabilized, other medication such as milrinone (ionotrope and venodilator) can be used.
  • Epinephrine is also fantastic for cold shock when the patient is clamped down with cold extremities – the most common presentation in pediatric septic shock.
  • Norepinephrine (noradrenaline) is best used when you need to augment systemic vascular resistance, such as in warm shock, where the patient has loss of peripheral vascular tone.

Induction Agent in Cardiogenic Shock

A blue baby – with a R –> L shuntneeds some pinking up with ketamine

A pink baby – with a L –> R shunt – is already doing ok – don’t rock the boat – give a neutral agent like etomidate.

Myocarditis or other acquired causes of cardiogenic shock – etomidate.  Ketamine is an acceptable alternative, but watch for tachydysrythmias.


Case 4: Status Epilepticus

Jessica is a 10-year-old girl with Lennox-Gastaut syndrome who arrives to your ED in status epilepticus.  She had been reasonably controlled on valproic acid, clonazepam, and a ketogenic diet, but yesterday she went to a birthday party, got into some cake, and has had stomach aches – she’s been refusing to take her medications today.

On arrival, she is hypoventilating, with HR 130s, BP 140/70, SPO2 92% on face mask.  She now becomes apneic.

Induction Agent in Status Epilepticus

Many choices, but we can use the properties of a given agent to our advantage. She is normo-to-hypertensive and tachycardic.  She has been vomiting. A nice choice here would be propofol.

  • Propofol as both a sedative and anti-epileptic agent works primarily on GABA-A and endocannabinoid receptors to provide a brief, but deep hypnotic sedation.  Side effects can include hypotension, which is often transient and resolves without treatment.  Apnea is the most common side-effect.
  • Ketamine would be another good choice here, for its anti-epileptic activity.

Paralytic Agent in Status Epilepticus

Rocuronium (in general), as there are concerns of a neurologic comorbidity.

Housekeeping in RSI

What size catheter do I use?  Based on ETT size, it is just a matter of multiplication by 2, 3, or 4.

Remember this: 2, 3, 4 – Tube, Tape, Tap

The NG/OG/Foley is 2 x the ETTtube

The ETT should be secured at a depth of 3 x the ETT sizetape

A chest tube size 4 x the ETTtap


In summary, in these cases of sepsis, multitrauma, cardiogenic shock, and status epilepticus:

  • Resuscitate before you intubate
  • Use the agent’s specific properties and talents to your benefit
  • Adjust the dose in critically ill patients: decrease the sedative, increase the paralytic
  • Have post-intubation care ready: analgesia, sedation, verification, NG/OG/foley

 

Selected References

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Choi S-H, Yi J-W, Rha Y-H. Rocuronium anaphylaxis in a 3-year-old girl with no previous exposure to neuromuscular blocking agents. Asian Pac J Allergy Immunol Launched Allergy Immunol Soc Thail. 2013;31(2):163-166.

Chon JY. In the hour of Sugammadex. Korean J Anesthesiol. 2013;64(1):3-5.

De Backer D, Biston P, Devriendt J, et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. N Engl J Med. 2010;362(9):779-789.

Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637.

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Henderson J, Popat M, Latto P, Pearce A. Difficult Airway Society guidelines. Anaesthesia. 2004;59(12):1242-1243; author reply 1247.

Henderson JJ, Popat MT, Latto IP, Pearce AC, Difficult Airway Society. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia. 2004;59(7):675-694.

Hildreth AN, Mejia VA, Maxwell RA, Smith PW, Dart BW, Barker DE. Adrenal suppression following a single dose of etomidate for rapid sequence induction: a prospective randomized study. J Trauma. 2008;65(3):573-579.

Ilina MV, Kepron CA, Taylor GP, Perrin DG, Kantor PF, Somers GR. Undiagnosed heart disease leading to sudden unexpected death in childhood: a retrospective study. Pediatrics. 2011;128(3):e513-e520.

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Kerrey BT, Mittiga MR, Rinderknecht AS, et al. Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department. BMJ Qual Saf. July 2015. doi:10.1136/bmjqs-2014-003713.
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Kogan A, Efrat R, Katz J, Vidne BA. Propofol-ketamine mixture for anesthesia in pediatric patients undergoing cardiac catheterization. J Cardiothorac Vasc Anesth. 2003;17(6):691-693.

Lee C. Goodbye suxamethonium! Anaesthesia. 2009;64 Suppl 1:73-81.

Lin C-C, Yu J-H, Lin C-C, Li W-C, Weng Y-M, Chen S-Y. Postintubation hemodynamic effects of intravenous lidocaine in severe traumatic brain injury. Am J Emerg Med. 2012;30(9):1782-1787. doi:10.1016/j.ajem.2012.02.013.

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Mallon WK, Keim SM, Shoenberger JM, Walls RM. Rocuronium vs. succinylcholine in the emergency department: a critical appraisal. J Emerg Med. 2009;37(2):183-188.

Marsch SC, Steiner L, Bucher E, et al. Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial. Crit Care Lond Engl. 2011;15(4):R199.

McRae ME. Long-term issues after the Fontan procedure. AACN Adv Crit Care. 2013;24(3):264-282; quiz 283-284.

Metterlein T, Frommer M, Ginzkey C, et al. A randomized trial comparing two cuffed emergency cricothyrotomy devices using a wire-guided and a catheter-over-needle technique. J Emerg Med. 2011;41(3):326-332.

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Neuhaus D, Schmitz A, Gerber A, Weiss M. Controlled rapid sequence induction and intubation – an analysis of 1001 children. Paediatr Anaesth. 2013;23(8):734-740.

Oklü E, Bulutcu FS, Yalçin Y, Ozbek U, Cakali E, Bayindir O. Which anesthetic agent alters the hemodynamic status during pediatric catheterization? Comparison of propofol versus ketamine. J Cardiothorac Vasc Anesth. 2003;17(6):686-690.

Patanwala AE, McKinney CB, Erstad BL, Sakles JC. Retrospective Analysis of Etomidate Versus Ketamine for First-pass Intubation Success in an Academic Emergency Department. Acad Emerg Med. 2014;21(1):87-91.

Perry JJ, Lee JS, Sillberg VAH, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. 2008;(2):CD002788.

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Reddy JI, Cooke PJ, van Schalkwyk JM, Hannam JA, Fitzharris P, Mitchell SJ. Anaphylaxis is more common with rocuronium and succinylcholine than with atracurium. Anesthesiology. 2015;122(1):39-45.

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Rinderknecht AS, Mittiga MR, Meinzen-Derr J, Geis GL, Kerrey BT. Factors associated with oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department: findings from multivariable analyses of video review data. Acad Emerg Med Off J Soc Acad Emerg Med. 2015;22(4):431-440.

Robinson N, Clancy M. In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. Emerg Med J EMJ. 2001;18(6):453-457.

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Scherzer D, Leder M, Tobias JD. Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients. J Pediatr Pharmacol Ther. 2012;17(2):142-149.

Scrase I, Woollard M. Needle vs surgical cricothyroidotomy: a short cut to effective ventilation. Anaesthesia. 2006;61(10):962-974.

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Sokolove PE, Price DD, Okada P. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000;16(1):18-21.

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Strayer RJ. Rocuronium versus succinylcholine: Cochrane synopsis reconsidered. Ann Emerg Med. 2011;58(2):217-218.

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Weiss M, Engelhardt T. Proposal for the management of the unexpected difficult pediatric airway. Paediatr Anaesth. 2010;20(5):454-464.

Zuckerbraun NS, Pitetti RD, Herr SM, Roth KR, Gaines BA, King C. Use of etomidate as an induction agent for rapid sequence intubation in a pediatric emergency department. Acad Emerg Med Off J Soc Acad Emerg Med. 2006;13(6):602-609.

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Rapid Sequence Intubation Portal on WikEM

 

This podcast and post are dedicated to Minh Le Cong, MBBS, FRACGP, FACRRM, FARGP, GDRGP, GCMA,GEM, Dip AeroMedical Retrieval & Transport, for his humble brilliance, fine example, and for being the life of the FOAMed party; and to Diane Birnbaumer, MD, FACEP, for her steadfast dedication to clinical and educational excellence, her stellar example, and her hard-won clinical prudence.

Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

Pediatric; Emergency Medicine; Pediatric Emergency Medicine; Podcast; Pediatric Podcast; Emergency Medicine Podcast; Horeczko; Harbor-UCLA; Presentation Skills; #FOAMed #FOAMped #MedEd

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  • Tal

    Great summary. I have 1 comment and 1 question.
    Comment: After a Fontan, kids should have sats in the relatively normal range, usually >88% if fenestrated, rather than 75-85%.
    Question: People often talk about bicarb in cardiac patients during resuscitation prior to intubation. Do you have any comment on this or does it seem to be mostly a style thing?
    Thanks,
    Tal

    • Thank you Tal for your kind words and your careful attention!

      I just realized that I needed to clarify. In general, CHD sats can range from 75-85%, especially post Norwood, post Glenn. Thank you for your comment — absolutely! S/p Fontan, sats improve 88-95%, less if fenestrated, the most common approach nowadays (fenestration really just an attempt to avoid post-op overload, complications). Thank you again — your comments made the post better — I adjusted the language to make it clearer.

      Regarding your question, I cannot say that I routinely intubate children with congenital heart disease (although have done my fair share!) Having said that, I have never given bicarb prophylactically, either in the ED in a patient in extremis, or in the OR for an elective procedure. I can see the logic, but my focus is on perfusion to avoid acidosis, with judicious aliquots of fluids, as these children are preload-dependent.

      Thanks very much for the great comments — really appreciate your taking the time!

    • Tim Horeczko

      Thank you Tal for your kind words and your careful attention!

      I just realized that I needed to clarify. In general, CHD sats can range from 75-85%, especially post Norwood, post Glenn. Thank you for your comment — absolutely! S/p Fontan, sats improve 88-95%, less if fenestrated, the most common approach nowadays (fenestration really just an attempt to avoid post-op overload, complications). Thank you again — your comments made the post better — I adjusted the language to make it clearer.

      Regarding your question, I cannot say that I routinely intubate children with congenital heart disease (although have done my fair share!) Having said that, I have never given bicarb prophylactically, either in the ED in a patient in extremis, or in the OR for an elective procedure. I can see the logic, but my focus is on perfusion to avoid acidosis, with judicious aliquots of fluids, as these children are preload-dependent.

      Thanks very much for the great comments — really appreciate your taking the time!

  • Jay Khadpe

    In the first case, you mention using ketamine as the induction agent in 2 month old with sepsis. Dr. Amy Drendel was on an episode of Emergency Medicine Cases (http://emergencymedicinecases.com/pediatric-procedural-sedation/) talking about pediatric procedural sedation and cautioned against using ketamine in children less than 3 months old due to increased risk of respiratory complications and animal studies suggesting NMDA antagonists are associated with apoptosis and neuro-degeneration in developing brains. Wanted to ask your thoughts on this?

    • Tim Horeczko

      Hi Jay!

      Thank you very much for the opportunity to clarify, and to distinguish the different indications of ketamine.

      Yes, for procedural sedation, ketamine should not be used in children less than 3 months of age, as there is a significant risk for apnea (especially dangerous if not identified and managed early).

      For intubation, particularly in sepsis, it is a safe agent (as you are working on protecting the airway), and recommended by current guidelines.

      There are animals studies suggesting apoptosis, and clinically we still do not know how to incorporate that information — if at all — into our practice. The truth is, developing brains do better without any anesthetic agent; we just have to choose our risk-to-benefit ratio. The literature on the effect of anesthetics on developing brains is evolving, from the traditional (“fear any anesthetic”) to the “not clinically significant” stance. We’ll have to stay tuned.

      In short, when our hand is forced to choose an agent, we can tailor our choice to the presentation. In sepsis, the immediate hemodynamic advantages far outweigh any theoretical risk (for now!).

      Thanks very much — appreciate the interaction! …and Hi Dr Drendel!

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