What is the recommended approach for pediatric rapid sequence intubation according to the AIDA pediatric intubation guidelines?

Pediatric Rapid Sequence Intubation: AIDA Guidelines

Primary Recommendation

For pediatric rapid sequence intubation, use a rapid-onset muscle relaxant with succinylcholine as first-line choice (age-adjusted dosing: 1.8 mg/kg <1 month, 2 mg/kg 1 month-1 year, 1.2 mg/kg 1-10 years, 1 mg/kg >10 years), or rocuronium 0.9-1.2 mg/kg if succinylcholine is contraindicated, combined with appropriate sedation and preoxygenation. 1, 2

Modified RSI Approach for Pediatric Patients

The French guidelines recommend a "controlled" or "modified" RSI technique specifically for children, which differs from classic adult RSI and has demonstrated superior safety outcomes 2:

• Preoxygenate with FiO₂ 0.8 to maximize oxygen reserves 2
• Administer deep anesthesia with opioid and hypnotic agent before muscle relaxation 2
• Use gentle bag-mask ventilation with peak inspiratory pressure <15 cmH₂O after muscle relaxant administration to prevent hypoxemia 2
• This modified approach decreases hypoxemia, hemodynamic complications, and difficult intubation compared to classic RSI, with no observed aspiration events in retrospective studies 2

Rationale for Modified Approach

Children desaturate much faster than adults due to higher metabolic oxygen consumption and lower functional residual capacity, making the apneic period between induction and intubation particularly dangerous 1. The traditional "no ventilation" dogma of adult RSI should be abandoned in pediatric patients 2.

Muscle Relaxant Selection Algorithm

First-Line: Succinylcholine

• Preferred agent for classic RSI due to rapid onset and short duration 1
• Age-specific dosing is critical (see above) 1
• Provides as good or better intubation conditions compared to rocuronium 1

Alternative: Rocuronium

• Use when succinylcholine is contraindicated (neuromuscular disease risk, hyperkalemia risk, malignant hyperthermia susceptibility) 1
• Dose: 0.9-1.2 mg/kg for RSI 1, 2
• Consider that reversal with sugammadex may not be universally available in all settings 1
• Base choice on desired duration of paralysis and risk of difficult intubation 1

Equipment and Technique Considerations

Endotracheal Tube Selection

• Both cuffed and uncuffed tubes are acceptable for pediatric intubation 1
• Cuffed tubes may be preferable in cases of poor lung compliance, high airway resistance, or large glottic air leak 1
• Monitor cuff pressure <20-25 cm H₂O when using cuffed tubes 1
• Have tubes 0.5 mm smaller and larger available than estimated size 1
• Length-based resuscitation tapes are more accurate than age-based formulas for children up to 35 kg 1

Videolaryngoscopy

• Use as first option for anticipated difficult intubation or after failed direct laryngoscopy 1
• Improves glottic visualization and increases first-attempt success rate in children with history of difficult intubation or polymalformative syndromes 1
• In routine cases without difficult airway predictors, videolaryngoscopy shows no significant advantage over direct laryngoscopy 1

Critical Safety Considerations

Cricoid Pressure: Controversial and Not Routinely Recommended

• Insufficient evidence to recommend routine cricoid pressure in pediatric intubation 1, 2
• Do not continue if it interferes with ventilation or ease of intubation 1, 2
• Some current guidelines no longer include cricoid pressure for pediatric aspiration-risk patients 2

Backup Plan Mandatory

• Must have a secondary airway management plan if intubation fails 1
• RSI should only be performed by trained, experienced providers proficient in pediatric airway evaluation and management 1

Common Pitfalls to Avoid

• Hypoxemia and hypotension are the most common adverse events (occurring in up to 39% of pediatric ED intubations) 3
• First-pass success without desaturation or hypotension is only 49% in real-world ED settings 3
• Gastric inflation can compromise ventilation—avoid excessive peak inspiratory pressures and ventilate slowly 1
• Use actual body weight, not ideal body weight, for dosing succinylcholine 1

Training and Experience Requirements

Successful pediatric intubation requires:

• Adequate training and supervised operating room experience 1
• Ongoing clinical experience to maintain proficiency 1
• Knowledge of pediatric airway anatomical differences 1
• Emergency medicine residents achieve 77% first-pass success under supervision in academic settings 4