What is the rapid sequence intubation (RSI) preparation for a 16kg child with status epilepticus and signs of cerebral edema?

From the Guidelines

For rapid sequence intubation (RSI) in a 16kg child with status epilepticus and cerebral edema, I recommend using etomidate 0.3 mg/kg (4.8mg total) as the induction agent, followed by rocuronium 1 mg/kg (16mg total) for paralysis, as suggested by the most recent and highest quality study 1. This approach is supported by the 2017 study published in Anaesthesia, which recommends succinylcholine as the first-line agent for RSI in pediatric patients with respiratory or cardiovascular compromise, but also suggests rocuronium as a suitable alternative when succinylcholine is contraindicated 1. Some key points to consider during the intubation process include:

• Pre-oxygenate thoroughly with 100% oxygen for 3-5 minutes if possible
• Use a cuffed endotracheal tube size 5.0 or 5.5, with a straight blade laryngoscope (Miller size 2) or curved blade (Mac size 2)
• Maintain head-neutral position during intubation to protect the cervical spine Post-intubation management should focus on reducing intracranial pressure, with strategies such as:
• Targeting mild hyperventilation with ETCO2 of 30-35 mmHg
• Starting with a tidal volume of 6-8 ml/kg and respiratory rate of 20-25 breaths per minute
• Considering administration of 3% hypertonic saline (3-5 ml/kg) or mannitol (0.25-1 g/kg) to further reduce cerebral edema after securing the airway
• Maintaining normothermia and elevating the head of bed to 30 degrees once intubated to optimize cerebral perfusion and reduce intracranial pressure. It is also important to note that ketamine should be avoided in this scenario, as it may worsen cerebral edema, and etomidate is preferred due to its ability to maintain hemodynamic stability and not increase intracranial pressure 1.

From the FDA Drug Label

The recommended initial intubation dose of rocuronium bromide injection is 0.6 mg/kg; however, a lower dose of 0.45 mg/kg may be used depending on anesthetic technique and the age of the patient. Rocuronium bromide injection is not recommended for rapid sequence intubation in pediatric patients.

For a 16kg child, the recommended initial intubation dose would be 0.6 mg/kg or 9.6 mg. However, since the child is having status epilepticus and neurological signs of cerebral edema, and considering the drug label does not provide specific guidance for rapid sequence intubation in pediatric patients, a conservative approach would be to avoid using rocuronium for RSI in this patient.

• The dose for RSI is not established for pediatric patients.
• Alternative neuromuscular blocking agents should be considered for RSI in pediatric patients 2.

From the Research

RSI Preparation for Intubation in a 16kg Child with Status Epilepticus and Cerebral Edema

• The child's condition requires immediate attention, and the management of status epilepticus is crucial in preventing further brain damage and improving outcomes 3, 4.
• The treatment approach for status epilepticus varies based on the time and treatment stage, with benzodiazepines being the first-line therapy during the emergent treatment phase 5.
• For a child with refractory status epilepticus, ketamine may be considered as a third-line medication, with studies showing its efficacy in terminating seizures 6, 7.
• In terms of intubation, there is no specific guidance in the provided studies for RSI preparation in a 16kg child with status epilepticus and cerebral edema.
• However, it is essential to consider the child's weight and medical condition when preparing for intubation, and to follow a predetermined management pathway to expedite care 4.
• The use of ketamine in refractory status epilepticus has been shown to be effective in terminating seizures, and its administration may be associated with improvement in hemodynamic stability 6, 7.