What are the recommended sedation and paralytic agents and doses for paediatric intubation?

Pediatric Rapid Sequence Intubation: Sedation and Paralytic Agents

For pediatric rapid sequence intubation, use ketamine (1-2 mg/kg IV) as the first-line sedative agent followed by succinylcholine (age-based dosing) as the first-line paralytic, with mandatory atropine pretreatment (0.01-0.02 mg/kg IV, max 0.5 mg) for all children aged 28 days to 8 years. 1, 2, 3

Pretreatment Medications

Atropine is essential for young children to prevent bradycardia during laryngoscopy and paralytic administration:

• Administer atropine 0.01-0.02 mg/kg IV (maximum 0.5 mg) to all children aged 28 days to 8 years 1, 2, 3
• Atropine is particularly critical in patients with septic shock, hypovolemia, or when using succinylcholine 1, 2
• The bradycardic response is more pronounced in younger children due to their vagal predominance 1

For patients with suspected elevated intracranial pressure:

• Consider lidocaine 1-2 mg/kg IV administered 30 seconds to 5 minutes before airway instrumentation 1, 2
• Note that evidence supporting lidocaine use is low quality, but it may provide theoretical benefit 1

Sedative-Hypnotic Agents

Ketamine is the preferred first-line sedative for most pediatric emergency intubations:

• Dose: 1-2 mg/kg IV 1, 2, 3
• Alternative dosing for very young children: 3-4 mg/kg before 18 months of age; 2 mg/kg after 18 months 2
• Ketamine maintains hemodynamic stability through sympathomimetic effects, making it ideal for hemodynamically unstable patients 1, 3
• Historical concerns about ketamine increasing intracranial pressure are not clinically significant, and it is now frequently used in head injury cases 3

Etomidate serves as an alternative first-line agent in specific circumstances:

• Dose: 0.2-0.4 mg/kg IV (maximum 20 mg) 1, 2
• Preferred in children over 2 years old with head injury due to minimal hemodynamic effects and reduction of intracranial pressure 1, 2
• Avoid in septic patients due to adrenal suppression concerns 2
• Etomidate has a significantly shorter duration of action (3-12 minutes) compared to long-acting paralytics, creating risk for awareness if additional sedation is not promptly administered 4

Propofol is reserved for elective or controlled situations:

• Dose: 2-4 mg/kg IV 2
• Not recommended for hemodynamically unstable patients due to hypotensive effects 5

Neuromuscular Blocking Agents

Succinylcholine remains the first-line paralytic for pediatric RSI when no contraindications exist:

• Age-based dosing: 1, 2
  • Children >10 years: 1-1.5 mg/kg IV
  • Children 1-10 years: 1.2 mg/kg IV
  • Infants 1 month to 1 year: 2.0 mg/kg IV
  • Neonates <1 month: 1.8 mg/kg IV
• Provides rapid onset (45-60 seconds) and short duration (5-10 minutes), allowing for reassessment if intubation fails 6, 7
• Contraindications include: hyperkalemia, crush injuries >8 hours old, burns >24 hours old, neuromuscular disease, malignant hyperthermia history 6

Rocuronium is the alternative when succinylcholine is contraindicated:

• Dose: 0.9-1.2 mg/kg IV 1, 2, 8
• Provides excellent intubating conditions within 60 seconds 3, 7
• Duration of action is significantly longer (25-73 minutes) compared to succinylcholine 4, 7
• Sugammadex must be immediately available when using rocuronium for potential reversal in "can't intubate, can't ventilate" scenarios 1, 2, 3

Critical Post-Intubation Sedation

A major pitfall is failure to provide ongoing sedation after the initial sedative wears off while the patient remains paralyzed:

• Most pediatric patients (72%) do not receive post-intubation sedation within an adequate timeframe 9
• When using etomidate with long-acting paralytics, 63% of patients received additional sedation more than 15 minutes after etomidate administration, and 13% received no additional sedation at all 4
• Patients receiving long-acting paralytics are significantly less likely to receive timely post-intubation sedation (OR 0.16) compared to those receiving succinylcholine 9

To prevent awareness during paralysis:

• Administer continuous sedation (midazolam or propofol infusion) immediately after intubation when using long-acting paralytics 3
• For midazolam: Initial dose 0.05-0.1 mg/kg IV for children 6 months to 5 years; 0.025-0.05 mg/kg IV for children 6-12 years 10
• Continuous infusion: 0.06-0.12 mg/kg/hr (1-2 mcg/kg/min) for intubated patients 10

Age-Specific Considerations

Neonates (<28 days) require special attention:

• Atropine dosing: 0.01-0.02 mg/kg IV (maximum 0.5 mg) 1
• Succinylcholine: 1.8 mg/kg IV 1
• Particularly vulnerable to airway obstruction and hypoventilation; titrate carefully 10
• For continuous sedation: Start at 0.03 mg/kg/hr (0.5 mcg/kg/min) for neonates <32 weeks; 0.06 mg/kg/hr (1 mcg/kg/min) for neonates >32 weeks 10
• Do not use loading doses of sedatives in neonates; run infusion more rapidly initially to establish therapeutic levels 10

Infants (1-12 months):

• Succinylcholine: 2.0 mg/kg IV 1
• Time to maximum block is shortest in this age group 8

Children (1-10 years):

• Succinylcholine: 1.2 mg/kg IV 1
• Duration of clinical relaxation is shortest in this age group 8

Common Pitfalls and How to Avoid Them

Never administer paralytics without ensuring adequate ongoing sedation:

• This is the most critical error, causing awareness during paralysis 3, 9, 4
• Set a timer or protocol to administer continuous sedation within 5-10 minutes of intubation when using long-acting paralytics 9, 4

Failure to give atropine in young children:

• This increases risk of clinically significant bradycardia, particularly with succinylcholine 1, 2
• Make atropine administration automatic for all children under 8 years 1

Using succinylcholine in patients with contraindications:

• Hyperkalemia can lead to cardiac arrest 1
• Screen for crush injuries, burns, neuromuscular disease, and recent immobilization 6

Not having sugammadex available when using rocuronium:

• Rocuronium's long duration becomes problematic in failed intubation scenarios 1, 2
• Ensure sugammadex is at bedside before administering rocuronium 3

Inadequate monitoring after intubation:

• Confirm tube placement with waveform capnography immediately and after any patient movement 3
• Target normocapnia (end-tidal CO2 of 4.0-4.5 kPa) as abnormal values are associated with increased mortality 3