389 Atropine Pretreatment and Adverse Events in Emergency Pediatric Intubation

Abstract

Atropine may blunt the vagal response to laryngoscopy and endotracheal intubation in children, though its role in emergency pediatric intubation remains unclear. Pediatric Advanced Life Support (PALS) guidelines recommend against the routine use of prophylactic atropine when intubating critically-ill children and infants, but state it “may be reasonable” in specific situations with high risk of bradycardia (eg, when using succinylcholine for paralysis). Our goal was to describe the use of atropine for pediatric intubation in the emergency department (ED) and estimate its association with peri-intubation adverse events (AE). We performed a secondary analysis of prospectively-collected data from the National Emergency Airway Registry (NEAR), a multicenter registry of academic and community EDs in the United States requiring reporting of ≥90% of intubations for participation. Patients ≤15 years of age were included from 2016 through 2018. We report proportions with associated 95% CIs and multivariable logistic regression estimating the association between atropine pretreatment and AEs including bradycardia, hypotension, cardiac arrest, and hypoxia while adjusting for age, pre-intubation blood pressure and oxygen saturation, sedative and paralytic choice, type of laryngoscopy, intubator level of training, number of attempts and clustering within hospitals. 25 EDs provided data for 612 pediatric intubations: 139 <1 year of age; 129 ages 1 year to <3 years; 144 ages 3 years to <8 years; and 200 ages 8 years to ≤15 years. While all intubations were ultimately successful, first pass success rate was 78%. Atropine pretreatment was given in 7% of intubations, of which, 51% were <1 year and 23% received succinylcholine. AEs occurred in 16% of intubation attempts with hypoxia being the most common AE; cardiopulmonary AEs occurred in 4%; bradycardia in 2%. Of the 9 patients who did not receive atropine pretreatment and experienced bradycardia, 6 received rocuronium for paralysis and 3 received succinylcholine. After adjusting for confounding, atropine pretreatment was associated with an increased occurrence of cardiopulmonary AEs (OR 2.60, 95% CI 1.02-6.61). In this multicenter prospective cohort of pediatric intubations, atropine pretreatment was uncommon and associated with increased adverse cardiopulmonary events. This finding challenges the use of atropine to prevent bradycardia in emergency pediatric intubation and further research is required to explore the unexpected association with cardiopulmonary adverse events.