Pediatric Rapid Sequence Intubation Research Articles

Current Practices and Safety of Medication Use During Pediatric Rapid Sequence Intubation

OBJECTIVES This study aimed to characterize medication-related practices during and immediately ­following rapid sequence intubation (RSI) in pediatric care units across the United States and to evaluate adverse drug events. METHODS This was a multicenter, observational study of medication practices surrounding intubation in pediatric and neonatal intensive care unit (NICU) and emergency department patients across the United States. RESULTS A total of 172 patients from 13 geographically diverse institutions were included. Overall, 24%, 69%, and 50% received preinduction, induction, and neuromuscular blockade, respectively. Induction and neuromuscular blocking agent (NMBA) use was low in NICU patients (52% and 23%, respectively), whereas nearly all patients intubated outside of the NICU received both (98% and 95%, respectively). NICU patients who received RSI medications were older and weighed more. Despite infrequent use of atropine (21%), only 3 patients developed bradycardia after RSI. Of the 119 patients who received an induction agent, fentanyl (67%) and midazolam (34%) were administered most frequently. Hypotension and hypertension occurred in 23% and 24% of patients, respectively, but were not associated with a single induction agent. Etomidate use was low and not associated with development of adrenal insufficiency. Rocuronium was the most used NMBA (78%). Succinylcholine use was low (11%) and administered despite hyperkalemia in 2 patients. Postintubation sedation and analgesia were not used or inadequate based on timing of initiation in many patients who received a non-depolarizing NMBA. CONCLUSIONS Medication practices surrounding pediatric RSI vary across the United States and may be influenced by patient location, age, and weight.

The Safety of Positive Pressure Ventilation in Pediatric Rapid Sequence Intubation

<h3>Introduction</h3> Prior data suggest that a higher preoxygenation target may be justified during pediatric rapid sequence intubation (RSI) to avoid oxygen desaturation. This may involve increased use of positive-pressure ventilation (PPV) in patients with initial SpO2 ≥94%. The safety of this approach is unknown. <h3>Methods</h3> All air medical pediatric RSI patients treated by a large air medical company over a 5-year period were included. Patients were stratified by initial SpO2 value [97-100%, 94-96%, <94%] and compared with regard to PPV use during preoxygenation and a reported complication of aspiration <h3>Results</h3> A total of 1,067 pediatric RSI patients were included. PPV rates increased with decreasing initial SpO2 [97-100%: 389/765 (51%), 94-96%: 78/130 (60%), <94%: 151/172 (88%)]. Increased aspiration rates with PPV were reported only in patients with initial SpO2 <94% vs ≥94% (3.3% vs 0.3%, p=0.011). <h3>Conclusion</h3> A low risk of aspiration with PPV was observed in air medical pediatric RSI patients with SpO2 values ≥94%. This may justify more aggressive use of PPV to achieve higher preoxygenation targets to avoid oxygen desaturation.

Pediatric Rapid Sequence Intubation Success with a Novel Training Program

<h3>Introduction</h3> Pediatric rapid sequence intubation (RSI) is a critical skill. PICU and ED physicians report first attempt success (FAS) rates of 62-78% and first attempt success without desaturation (FASWD) rates of 58%. Here we report air medical pediatric RSI success rates using a novel training program [HeART]. <h3>Methods</h3> All pediatric RSI patients over a five-year period (2015-2019) from a large air medical company were included. FAS and FASWD were calculated for all patients and for specific age cohorts [0-2 years, 3-8 years, 9-17 years]. Meta-analysis was performed to compare to reported physician success rates. <h3>Results</h3> A total of 1,116 pediatric RSI patients were included [0-2: n=247, 3-8: n=250, 9-17: n=619]. Intubation success rates were similar across age groups. Both FAS and FASWD rates were significantly higher than reported for PICU and ED physicians (FAS = 91% vs 61%, p<0.001; FASWD = 63% vs 58%, p=0.034). <h3>Conclusion</h3> We observed high FAS and FASWD rates for air medical pediatric RSI using a novel airway curriculum. Although RSI success rates were higher than reported for PICU and ED physicians, the comparisons may reflect undetected differences in various airway difficulty factors.

The Optimal Preoxygenation Target to Avoid Desaturation During Pediatric Rapid Sequence Intubation

<h3>Background</h3> Rapid sequence intubation (RSI) is a critical procedure in the resuscitation of critically ill and injured patients but carries an important risk of oxygen desaturation. In the adult population, a target preoxygenation threshold of >93% has been defined. However, it is not known whether this is an appropriate target for pediatric patients. <h3>Objective</h3> To define a target preoxygenation threshold for pediatric RSI. <h3>Methods</h3> Our air medical agency includes 150 bases, with a flight RN/flight paramedic crew configuration. The pediatric RSI protocol includes the use of etomidate or ketamine for induction and either succinylcholine or rocuronium for paralysis. Up to 120 data elements are entered into the Institutions Airway Database for each RSI procedure. For this analysis, all pediatric patients (age <18 years) undergoing RSI between January 2015 and September 2019 were included. Separate analysis was performed for infants (0-2 years), young children (3-8 years), and older children (9-17 years). Patients werestratified by highest pre-attempt SpO2 value, with the rate of desaturation identified as the primary outcome measure. Desaturation was defined as decrease in SpO2 to <94% or a continued decrease by at least 2% if pre-attempt SpO2 value was <94%. A graphical analysis was performed to identify an inflection point below which substantially higher desaturation rates were observed. The desaturation rate for patients with pre-attempt SpO2 values above that threshold were compared to those below that threshold using chi-square analysis, with significance was set at p<0.05. <h3>Results</h3> A total of 1,116 patients were identified over the 57-month period (infant n=247, young children n=250, older children n=619). A clear desaturation rate inflection point was observed with pre-attempt SpO2 values of 97% or greater. For patients with pre-attempt SpO2 values of <97%, the desaturation rate was 59.2% as compared to 12.8% with pre-attempt SpO2 values of 97% or greater (OR 9.8, 95% CI 6.9-14.1, p<0.0001). These results were similar across the three age groups. <h3>Conclusions</h3> These data support a higher preoxygenation target of 97% or greater with pediatric RSI. Limitations include the observational nature of the analysis and the possibility that lower pre-attempt SpO2 is a surrogate for more a difficult airway.

Incidence of Bradycardia and the Use of Atropine in Pediatric Rapid Sequence Intubation in the Emergency Department.

Bradycardia during rapid sequence intubation (RSI) is an uncommon but serious adverse effect encountered in pediatric intubations. Atropine has historically been used in the pediatric population as RSI premedication to prevent bradycardia, especially when using succinylcholine as an induction agent. The objective of this analysis was to identify the incidence of bradycardia with or without atropine use. This single-center, retrospective, observational case series reviewed pediatric patients up to 18 years old requiring intubation from January 1, 2015, to December 31, 2018. Bradycardia was determined by analyzing heart rates associated with time during and up to 5 minutes after intubation. A total of 62 patients were included. Three (4.8%) patients experienced a bradycardic event during intubation. A total of 15 (24.2%) patients received atropine for pretreatment of RSI. Incidence of bradycardia was similar between those who received atropine and those who did not. An increasing trend in atropine use was shown throughout the assessment period, yet only 18 (29%) patients met criteria for atropine pretreatment based on the 2015 Pediatric Advanced Life Support guideline recommendations for RSI. Bradycardia incidence was low in pediatric patients undergoing RSI in our emergency department. Use of atropine or succinylcholine did not affect the incidence of bradycardia during pediatric intubation over this study period. Our results show a low incidence of bradycardia and support the 2015 Pediatric Advanced Life Support Guideline recommendation of limiting the use of atropine premedication in pediatric intubations.

Don't Hold Your Breath-A Video-Based Study of Procedural Intervals During Pediatric Rapid Sequence Intubation.

Develop a framework for data collection to determine the contributions of both laryngoscopy and tube delivery intervals to the apneic period in unsuccessful and successful attempts among patients undergoing rapid sequence intubation (RSI) in a pediatric emergency department (PED). This was a retrospective, observational study of RSI. An academic PED. A consecutive sample of all intubations attempts of first provider physicians performing RSI in the shock trauma suite over a 10-month period in 2018-2019. Data were collected by structured video review. The main outcome was the duration of the laryngoscopy and tube delivery intervals per attempt. We compared interval duration between successful and unsuccessful attempts, adjusting for age, accounting for repeated measures, and clustering by provider. There were 69 patients with 89 total intubation attempts. Sixty-three patients were successfully intubated by the first provider (91%). Pediatric emergency medicine fellows performed 54% of the attempts. The median duration of the apneic period per attempt was longer in unsuccessful attempts (57 vs 44 seconds; median of difference, -10.5; 95% confidence interval [CI], -17.0 to -4.0). The duration of laryngoscopy was similar (18 vs 13 seconds; median of difference, -3.5; 95% CI, -8.0 to 1.0), but tube delivery was longer in unsuccessful attempts (25.5 vs. 11 seconds; median of difference, -12.5; 95% CI, -17.0 to -4.0). These results did not change when adjusting for age or clustering by provider. We successfully developed a specific, time-based framework for the contributors to prolonged apnea in RSI. Prolonged tube delivery accounted for more of the apneic period. Future studies and improvement should focus on problems during tube delivery in the PED.

Application of a Healthcare Failure Modes and Effects Analysis to Identify and Mitigate Potential Risks in the Implementation of a National Prehospital Pediatric Rapid Sequence Intubation Program.

Rapid sequence intubation (RSI) has become the de facto airway method of choice in the emergency airway management of adult and pediatric patients. There is significant controversy regarding pediatric RSI in the prehospital setting, given not only the complexities inherent in both the procedure and patient population, but in variations in emergency medical service models, prehospital qualifications, scope of practice, and patient exposure too. A Healthcare Failure Mode and Effects Analysis was conducted to identify and mitigate potential hazards in the national implementation of a prehospital pediatric RSI program. A process map and potential failure points were developed and identified. Probabilities, severity, and hazards scores were calculated for each failure point, and actions items developed to address these. One hundred four potential failure points were identified among 44 subprocesses, divided between nine major processes. In terms of severity, most were classified as either major (n = 39 [37.5%]) or catastrophic (n = 35 [33.7%]) with just more than half falling within the uncommon category (n = 56 [53.9%]) in terms of probability. Five strategic actions items were identified to mitigate against the failure points meeting criteria for action. To monitor the success of these, 11 quality and performance indicators were developed for concurrent implementation. The Healthcare Failure Mode and Effects Analysis represents a simple yet comprehensive first step toward risk analysis of complex procedures within the prehospital emergency care setting. Application of the methodology provided guidance for the consensus identification of hazards associated with prehospital pediatric RSI and appropriate actions to mitigate them.

OSATS Tool for Pediatric Rapid Sequence Intubation

Abstract Introduction Being procedurally competent to perform pediatric rapid sequence intubation (pRSI) is an ACGME requirement for emergency medicine residents. There are few assessment tools to ...

Pediatric Rapid Sequence Intubation: Video Reviews Are Revealing

To evaluate success rates and adverse effects of pediatric rapid sequence intubation (RSI), researchers reviewed video recordings and medical records

Prospective Comparison of Live Evaluation and Video Review in the Evaluation of Operator Performance in a Pediatric Emergency Airway Simulation

Real-time assessment of operator performance during procedural simulation is a common practice that requires undivided attention by 1 or more reviewers, potentially over many repetitions of the same case. To determine whether reviewers display better interrater agreement of procedural competency when observing recorded, rather than live, performance; and to develop an assessment tool for pediatric rapid sequence intubation (pRSI). A framework of a previously established Objective Structured Assessment of Technical Skills (OSATS) tool was modified for pRSI. Emergency medicine residents (postgraduate year 1-4) were prospectively enrolled in a pRSI simulation scenario and evaluated by 2 live raters using the modified tool. Sessions were videotaped and reviewed by the same raters at least 4months later. Raters were blinded to their initial rating. Interrater agreement was determined by using the Krippendorff generalized concordance method. Overall interrater agreement for live review was 0.75 (95% confidence interval [CI], 0.72-0.78) and for video was 0.79 (95% CI, 0.73-0.82). Live review was significantly superior to video review in only 1 of the OSATS domains (Preparation) and was equivalent in the other domains. Intrarater agreement between the live and video evaluation was very good, greater than 0.75 for all raters, with a mean of 0.81 (95% CI, 0.76-0.85). The modified OSATS assessment tool demonstrated some evidence of validity in discriminating among levels of resident experience and high interreviewer reliability. With this tool, intrareviewer reliability was high between live and 4-months' delayed video review of the simulated procedure, which supports feasibility of delayed video review in resident assessment.

Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation

Succinylcholine is often used to facilitate neonatal and pediatric rapid sequence intubation in the emergency department, and most relevant literature recommends administering atropine prior to succinylcholine to reduce the risk of bradycardia. Given the potential complications associated with combining these medications, we searched the published literature for evidence supporting this practice. Most studies recommending atropine premedication were undertaken in the operating room setting and pertained to repeated succinylcholine dosing. Furthermore, there is little published evidence to indicate that succinylcholine-related bradycardia is a clinically important side effect. Several authors have called for the practice to cease, but, to date, these calls have gone unheeded. We found no evidence supporting atropine's use in pediatric patients prior to single-dose succinylcholine. Atropine premedication for emergency department rapid sequence intubation is unnecessary and should not be viewed as a "standard of care."

Pediatric rapid sequence intubation: a review.

Pediatric rapid sequence intubation is a skill of great importance to emergency medicine physicians. Developing a systematic strategy for approaching an emergent airway aids in the proper handling of this event. This paper is a review of the current recommendations for pediatric rapid sequence intubation including current medications and surgical rescue techniques.

Etomidate for rapid-sequence intubation in young children: hemodynamic effects and adverse events.

Physicians commonly use etomidate for adult rapid-sequence intubation (RSI), but the manufacturer does not recommend its use for children under 10 years of age due to a lack of data. The authors present their experience with etomidate for pediatric RSI in order to further develop its risk-benefit profile in this age group. Trained abstractors reviewed the medical records for all children under 10 years old who received etomidate for RSI between July 1996 and April 2001. 105 children, with an average age of 3 (+/-2.9) years, received a median dose of 0.32 (+/-0.12) mg/kg of etomidate. The systolic blood pressure increased an average of 4 mm Hg (95% CI = -3.3 to 9.2); the diastolic blood pressure increased 7 mm Hg (95% CI = -3.1 to 11) within 10 minutes of receiving etomidate. The heart rate increased an average of 10 beats/min (95% CI = 4.0 to 17.4). Complications included three patients who vomited within 10 minutes of etomidate administration. There were no cases of documented myoclonus, status epilepticus, or new-onset seizures. Thirty-eight patients received corticosteroids during the hospital course, none for suspected adrenal insufficiency. Three patients died, all from severe brain injury. In children less than 10 years old, etomidate seems to produce minimal hemodynamic changes, and appears to have a low risk of clinically important adrenal insufficiency, myoclonus, and status epilepticus. The association between etomidate and emesis (observed in less than 3% of enrolled patients) remains unclear. For clinical situations in which minimal blood pressure changes during RSI are critical, etomidate appears to have a favorable risk-benefit profile for children under 10 years old.

Out-of-hospital Pediatric Rapid-sequence Intubation by an Aeromedical Provider

Out-of-hospital Pediatric Rapid-sequence Intubation by an Aeromedical Provider

The safety of etomidate for emergency rapid sequence intubation of pediatric patients

To determine whether pediatric patients given etomidate for rapid sequence intubation (RSI) in the ED develop clinically important hypotension or adrenal insufficiency. Retrospective review of 100 consecutive patients younger than age 10 years given etomidate for RSI in the ED at two academic medical centers. Data were abstracted from ED and in-patient medical records. Clinically important hypotension was defined as a decrease in systolic blood pressure (BP) measurement to below one standard deviation (SD) of mean normal for age. Clinically important adrenal insufficiency was defined as the need for exogenous corticosteroid replacement for suspected adrenal insufficiency at any time during hospitalization. BP measurements before and within 20 minutes after etomidate administration for RSI were recorded on 84 intubations (84%). The mean change in BP between pre-intubation and post-intubation measurements was a decrease of 1 mmHg (95% CI: -6 mm Hg to +7 mm Hg, P = 0.83). When expressed as a percentage of normal BP for age, the mean change in BP was a decrease of 1% (95% CI: -7% to +6%, P = 0.82). Four patients (4.8%; 95% CI: 1.3-11.7%) had a systolic BP decrease to below one SD of mean normal for age. Fourteen patients received corticosteroids during hospitalization, but none (0/99, 95% CI: 0-3.7%) for suspected adrenal insufficiency. We found no evidence of clinically important adrenocorticoid suppression and a low incidence of clinically important hypotension when using etomidate for emergent pediatric RSI. Because other induction agents may also result in hypotension, prospective comparison studies are needed to further evaluate the safety of etomidate in this patient population.