What is the protocol for rapid intubation in pediatric (pediatrics) patients?

From the Guidelines

Rapid sequence intubation (RSI) in pediatric patients should be performed using a controlled rapid sequence induction technique, which includes preoxygenation, deep anesthesia with an opiate and a hypnotic agent, and gentle bag and mask ventilation before laryngoscopy, as it has been shown to decrease the incidence of hypoxemia and hemodynamic complications. This approach is supported by the most recent and highest quality study, which suggests that the traditional rapid sequence induction technique should be abandoned in favor of the controlled version, except in specific cases such as bleeding tonsil 1.

When performing RSI in pediatric patients, it is essential to carefully select medications tailored to the child's age and condition.

• Preoxygenation for 3-5 minutes with 100% oxygen is crucial to prevent hypoxemia.
• Essential equipment includes appropriately sized endotracheal tubes, laryngoscope blades, and suction devices.
• Medications such as atropine (0.01-0.02 mg/kg) can be used to prevent bradycardia, especially in children under 1 year.
• Sedative options include etomidate (0.3 mg/kg), ketamine (1-2 mg/kg), or propofol (1-3 mg/kg).
• For paralysis, rocuronium (1 mg/kg) provides longer duration, while succinylcholine (1-2 mg/kg) offers faster onset but has more contraindications, and its use is probably not recommended except in situations where rapid-sequence induction is indicated 1.
• After administering medications, wait 45-60 seconds before attempting intubation.
• Position the patient with slight neck extension for older children or neutral position for infants.
• Confirm tube placement with end-tidal CO2 detection, chest rise, and auscultation.
• Post-intubation, secure the tube, obtain chest X-ray, and initiate appropriate ventilator settings.

It is also important to note that children desaturate more quickly than adults due to higher oxygen consumption and lower functional residual capacity, so maintaining oxygenation throughout the procedure is critical 1. Always have backup airway devices ready, including supraglottic airways and equipment for needle cricothyrotomy if conventional intubation fails. The use of actual body weight, rather than ideal body weight, is recommended for calculating medication doses, such as succinylcholine 1.

From the FDA Drug Label

For emergency tracheal intubation or in instances where immediate securing of the airway is necessary, the intravenous dose of succinylcholine is 2 mg/kg for infants and small pediatric patients; for older pediatric patients and adolescents the dose is 1 mg/kg It is currently known that the effective dose of succinylcholine in pediatric patients may be higher than that predicted by body weight dosing alone. Rarely, intravenous bolus administration of succinylcholine in infants and pediatric patients may result in malignant ventricular arrythmias and cardiac arrest secondary to acute rhabdomyolysis with hyperkalemia. Intravenous bolus administration of succinylcholine in infants or pediatric patients may result in profound bradycardia or, rarely, asystole. The occurrence of bradyarrhythmias may be reduced by pretreatment with atropine

Fast Intubation in Pediatrics:

• The recommended dose of succinylcholine for emergency tracheal intubation in pediatric patients is 2 mg/kg for infants and small pediatric patients and 1 mg/kg for older pediatric patients and adolescents 2.
• The effective dose of succinylcholine in pediatric patients may be higher than predicted by body weight dosing alone.
• Malignant ventricular arrhythmias and cardiac arrest may occur rarely in pediatric patients due to acute rhabdomyolysis with hyperkalemia.
• Profound bradycardia or asystole may also occur in pediatric patients.
• Pretreatment with atropine may reduce the occurrence of bradyarrhythmias 2.
• The use of succinylcholine in pediatric patients should be reserved for emergency intubation or instances where immediate securing of the airway is necessary 2.

From the Research

Definition and Principles of Fast Intubation in Pediatrics

• Fast intubation, also known as rapid sequence intubation (RSI), is a technique used for tracheal intubation in pediatric patients, especially in emergency situations 3.
• The principles of RSI include rapid creation of ideal intubating conditions, attenuation of pathophysiologic reflex responses, and reduction of the risk for pulmonary aspiration 3.
• RSI has two basic technical components: induction of general anesthesia and direct laryngoscopy with tracheal intubation 3.

Techniques and Modifications

• A modified rapid sequence intubation (MRSI) may be used in certain situations, with the majority of respondents defining it as equivalent to RSI but with mask ventilation 4.
• The technique of MRSI varies among pediatric care providers, with the major indication of use being a concern about apnea time tolerance with traditional RSI 4.
• A systematic strategy for approaching an emergent airway is essential for the proper handling of pediatric RSI 5.

Pharmacotherapy and Medication Considerations

• The selection and use of medications to facilitate RSI is critical for success, with several steps to the intubation process requiring medication considerations 6.
• Pretreatment medications, such as atropine, lidocaine, and fentanyl, are not commonly used due to limited evidence for their use outside of select clinical scenarios 6.
• Etomidate and ketamine are the most commonly used induction agents due to their favorable hemodynamic profiles, with etomidate potentially producing less hypotension than ketamine in patients with shock or sepsis 6.
• Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, with selection based on patient-specific factors, half-life, and adverse effect profiles 6.

Quality Improvement and Safety

• Implementation of a standardized process can significantly improve successful intubations within two attempts for medical and trauma patients 7.
• Adherence to the standardized process is essential for minimizing the risk of adverse complications, with a quality assurance program important for monitoring care 3, 7.
• Anticipation, recognition, and management of complications, including the unanticipated difficult airway, are critical for the competent delivery of RSI 3.