From the Guidelines
Atropine pretreatment is recommended for pediatric patients from 28 days to 8 years of age who require intubation, particularly in children with septic shock, hypovolaemia, or when suxamethonium is used. The standard dose is 0.02 mg/kg given intravenously 1-3 minutes before intubation, with no minimum dose specified in the most recent guidelines 1. This pretreatment is necessary because young children have a predominant vagal tone, making them particularly susceptible to the vagal effects of intubation, which can cause clinically significant bradycardia or even asystole. Some key points to consider when deciding to pretreat with atropine include:
- The patient's age and underlying medical condition, as children under 8 years are at higher risk of bradycardia during intubation 1
- The use of suxamethonium, which can stimulate muscarinic receptors in the heart and trigger a vagal response 1
- The presence of septic shock or hypovolaemia, which can increase the risk of haemodynamic decompensation during intubation 1 Recent studies have shown that atropine pretreatment can reduce the incidence of arrhythmias and mortality in pediatric patients undergoing intubation 1. However, the evidence is not uniform, and some studies have reported conflicting results 1. In clinical practice, the decision to pretreat with atropine should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical condition. It is also important to note that atropine is not recommended for routine use in all pediatric intubations, but rather in specific situations where the risk of bradycardia is higher 1. Overall, the use of atropine pretreatment in pediatric patients requiring intubation should be guided by the most recent and highest-quality evidence, with a focus on minimizing morbidity, mortality, and improving quality of life 1.
From the Research
Atropine Pretreatment in Pediatric Patients
- The age at which to pretreat pediatric patients with atropine is not explicitly stated in the provided studies, but the studies suggest that the routine use of atropine before succinylcholine in children may not be necessary 2, 3.
- A study published in 1995 found that the incidence of bradycardia after succinylcholine in children aged 1-12 years was lower than previously estimated, and the use of atropine before a single dose of succinylcholine in children deserves to be reconsidered 2.
- Another study published in 2005 found that there is no evidence supporting the use of atropine in pediatric patients prior to single-dose succinylcholine, and atropine premedication for emergency department rapid sequence intubation is unnecessary 3.
- A study comparing the haemodynamic effects of atropine and glycopyrrolate at induction of anaesthesia in children found that glycopyrrolate offered better cardiovascular stability and fewer arrhythmias compared to atropine 4.
- The American Heart Association recommended pediatric atropine dose is not specified in the provided studies, but a study published in 2022 found that certified registered nurse anesthetists (CRNAs) who were aware of guidelines reported the correct dose 100% of the time, whereas those unaware of guidelines reported the correct dose only 65% of the time 5.
Key Findings
- Atropine may not be necessary before succinylcholine in children 2, 3.
- Glycopyrrolate may be a better alternative to atropine in pediatric patients due to its better cardiovascular stability and fewer arrhythmias 4.
- CRNAs who are aware of guidelines are more likely to report the correct pediatric atropine dose 5.