What medications are recommended for pediatric patients undergoing Rapid Sequence Intubation (RSI)?

Pediatric Rapid Sequence Intubation Medications

For pediatric RSI, administer atropine (0.01-0.02 mg/kg IV) to children aged 28 days to 8 years, followed by ketamine (1-2 mg/kg IV) as the first-line sedative-hypnotic, and succinylcholine as the first-line neuromuscular blocker (age-adjusted dosing: 1.8 mg/kg for neonates <1 month, 2.0 mg/kg for infants 1 month to 1 year, 1.2 mg/kg for children 1-10 years, 1.0-1.5 mg/kg for children >10 years), with rocuronium (0.9-1.2 mg/kg IV) reserved for when succinylcholine is contraindicated. 1, 2

Pretreatment Phase

Atropine Administration

• Atropine is mandatory for all children aged 28 days to 8 years, particularly those with septic shock, hypovolemia, or when succinylcholine will be used 1, 2, 3
• Dose: 0.01-0.02 mg/kg IV (maximum 0.5 mg) 1, 2
• Atropine prevents clinically significant bradycardia during laryngoscopy and from succinylcholine-induced vagal stimulation in young children 1, 2

Lidocaine (Optional)

• Consider lidocaine 1-2 mg/kg IV administered 30 seconds to 5 minutes before airway instrumentation only in patients with elevated intracranial pressure 1, 2
• Evidence for lidocaine use is low quality and should not be routine 1

Sedative-Hypnotic Agent Selection

First-Line: Ketamine

• Ketamine (1-2 mg/kg IV) is the preferred induction agent for pediatric RSI, especially in hemodynamically unstable patients 1, 2, 3
• Ketamine maintains cardiovascular stability through sympathomimetic effects and catecholamine release 1, 2, 3
• Historical concerns about ketamine increasing intracranial pressure are not clinically significant, making it safe even in head injury patients 3

Alternative: Etomidate

• Etomidate (0.2-0.4 mg/kg IV, maximum 20 mg) serves as an alternative first-line agent, particularly in children over 2 years old (except in sepsis) 1, 2
• Etomidate has minimal hemodynamic effects and reduces intracranial pressure 1, 2
• No mortality difference exists between etomidate and other induction agents in critically ill patients 3

Avoid: Propofol

• Propofol (2-4 mg/kg IV) should not be used in hemodynamically unstable patients due to significant hypotensive effects 1, 2
• Propofol is reserved for elective procedures only 2

Neuromuscular Blocking Agent Selection

First-Line: Succinylcholine

• Succinylcholine remains the first-line neuromuscular blocker for pediatric RSI in children with respiratory or cardiovascular compromise 4, 1, 2
• Age-adjusted dosing is critical 4, 1, 2:
  • Neonates <1 month: 1.8 mg/kg IV
  • Infants 1 month to 1 year: 2.0 mg/kg IV
  • Children 1-10 years: 1.2 mg/kg IV
  • Children >10 years: 1.0-1.5 mg/kg IV
• Succinylcholine provides the fastest onset and shortest duration of action 4

Alternative: Rocuronium

• Rocuronium (0.9-1.2 mg/kg IV) is recommended when succinylcholine is contraindicated 4, 1, 2, 5
• Rocuronium at doses >0.9 mg/kg provides excellent intubating conditions within 60 seconds 4, 3
• Sugammadex must be immediately available when rocuronium is used for potential reversal in "can't intubate, can't ventilate" scenarios 1, 2, 3
• The FDA label indicates rocuronium is not recommended for rapid sequence intubation in pediatric patients, though clinical guidelines support its use as an alternative to succinylcholine 5

Critical Contraindications and Pitfalls

Succinylcholine Contraindications

• Never use succinylcholine in patients with primary muscle damage (myopathies) or chronic motor deficit with up-regulation of nicotinic acetylcholine receptors 4
• Avoid succinylcholine in hyperkalemia, as it can precipitate cardiac arrest 1, 6
• Depolarizing muscle relaxants should not be used for conventional intravenous induction outside of rapid-sequence context 4

Common Errors to Avoid

• Failure to administer atropine in children under 8 years, particularly when using succinylcholine, significantly increases bradycardia risk 1, 3
• Never administer neuromuscular blockers without adequate sedation, as this causes awareness during paralysis 3
• Failure to have sugammadex immediately available when using rocuronium can lead to inability to reverse paralysis in failed intubation scenarios 1, 2

Post-Intubation Management

Ongoing Sedation

• Most patients require continuous hypnotic drugs (midazolam or propofol) to maintain sedation during transport after neuromuscular blockade 3
• Accidental awareness is more likely when neuromuscular blocking drugs are used, particularly in emergency patients 3
• Post-intubation sedation and analgesia are frequently inadequate or delayed in clinical practice, especially after non-depolarizing NMBA use 6