Today I reviewed the podcast, link to, and excerpt from PedsCrit‘s* Intubation Essentials with Dr. Alyssa Stoner and Dr. Gina Patel, Part 4 Sedation & Analgesia Overview
JULY 22, 2021 PEDSCRIT
*This PedsCrit link is to a complete list of all the topics covered on this wonderful site. At the time of this post, there are 78 pediatric critical care topics covered.
All that follows is from today’s resource.
Intubation Essentials– Part 4 Sedation & Analgesia Overview
About our guests:
Dr. Alyssa Stoner is an Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine and practicing pediatric intensivist at Children’s Mercy Kansas City.
Dr. Gina Patel is a fellow in pediatric critical care at Children’s Mercy Kansas City.
Transcript of the podcast*
*I prepared this podcast transcription with a dictation service and I proofed it. I am a primary care physician. The creators of the podcast had no involvement in or responsibility for the preparation of this transcript.
Speaker 1 (00:00):
The Fentanyl Versed rocuronium approach is the standard approach that we use.
Speaker 2 (00:13):
Hi everyone, and welcome back to the PedsCDCrit podcast. My name is Zach Hodges and I’m a current PICU fellow at UT Southwestern in Dallas.
Speaker 3 (00:21):
And I’m Alice Shanklin. I’m a peds ICU fellow at Children’s National Hospital in Washington DC.
Speaker 2 (00:26):
Alice, will you remind our listeners what we do here at the PedsCrit Podcast?
Speaker 3 (00:30):
Yes, we are a collaborative educational PICU podcast. We’re working with pediatric critical care educators across the United States and internationally to create high yield blog and podcast episodes on core PICU topics.
Speaker 2 (00:43):
And listeners, if you’re a pediatric critical care provider and would like to become involved in this project, be sure to reach out to us by email or on our email@example.com. We’re hoping to create a space to further add to the online community of Peds ICU learners by collaborating with guest educators on their favorite critical care topics.
Speaker 3 (01:00):
Yes, please reach out. We would be so excited to hear from you now, Zach, who are we talking with today?
Speaker 2 (01:05):
So today we’re excited to have Dr. Gina Patel and Dr. Alyssa Stoner back on the show. So Dr. Stoner is an assistant professor of pediatrics at the University of Missouri, Kansas City School of Medicine and is a pediatric intensivist at Children’s Mercy, Kansas City.
Speaker 3 (01:20):
Yes. And Dr. Gina Patel is a second year peds critical care fellow at Children’s Mercy as well. In these episodes we’re talking about the medications required for intubation,
Speaker 2 (01:29):
And on part one, today’s episode we’re discussing rapid sequence versus delayed sequence intubation and describing a mental framework for how to choose the appropriate medication.
Speaker 3 (01:39):
Yes, we are so excited to share their perspectives and what we learned along the way. Let’s get to the episode. We are here today with Dr. Gina Patel and Dr. Alyssa Stoner. Where are you two coming to us from?
Speaker 4 (01:53):
Hey guys, I’m Gina Patel and I’m a second year PICU fellow at Children’s Mercy Hospital in Kansas City.
Speaker 1 (01:59):
And I am Melissa Stoner. I’m one of the faculty at Children’s Mercy helping train Gina.
Speaker 2 (02:06):
And we’re glad to have you back on the podcast to talk about sedation for intubation.
Speaker 4 (02:09):
Thank you for having us.
Speaker 3 (02:11):
So let’s start with just the basics. How would you define delayed sequence intubation versus rapid sequence intubation?
Speaker 1 (02:17):
Yeah, so that’s a great question. So rapid sequence intubation is a situation in which you are going to, as the title alludes to, rapidly get somebody ready for intubation. And so in this particular scenario, the medications are given immediately one right after another to then facilitate a rapid induction of anesthesia. Then to provide an opportunity to provide intubation for this patient. It’s typically utilized to avoid emesis and subsequent pulmonary aspiration. So when you’re thinking about somebody who maybe has a full stomach. If you’re thinking about the adult population, you’ll always hear that a pregnant woman always has a full stomach. So they always require rapid sequence intubation, mostly because they have delayed gastric emptying related to the pregnancy. And the goal is to avoid insufflation of the stomach. So during this procedure you preoxygenate the person with a hundred percent oxygen, you push the meds as fast as possible and you do not provide bag mask ventilation.
And then once they’re paralyzed and the amount of time has gone by in which the medication should take in effect, you provide your ability to look at their vocal cords and whichever approach you’re going to take. So either direct laryngoscopy or video laryngoscopy. It is supposed to be avoided in patients with difficult airways. And part of the reason for that is because if you are unable to provide bag mask ventilation and you’re unable to intubate the airway appropriately, you are in big trouble because you will have complete loss of airway and you may have to allude to a surgical airway in that case. So being mindful of that. So then when you contrast that to delayed sequence intubation, this is the approach that you’re going to take where you are going to more cautiously provide sedation. So you’re going to administer your analgesic, you’re going to administer your amnestic, you’re going to get the patient adequately sedated, maybe not quite apnic, and then you’re going to provide some kind of what we would call a test bag mask ventilation to see if this patient is going to be adequately ventilated while you beg mask them in a paralyzed state.
If you’re able to bagg them, then you’re safe to go ahead and give the paralytic. And so that provides the opportunity to know that you’re going to be able to support them through that process of while they’re paralyzed and allow for them to get intubated effectively.
Speaker 2 (04:42):
So if I’m understanding correctly, rapid sequence intubation, you give all your medicines upfront, including your neuromuscular blockade to try to completely take over the airway before there’s a high risk of aspiration; benefits being just that, but the risk would be if you can’t get that airway, you’re not quite sure you can actually bag the patient?
Speaker 1 (05:03):
Speaker 2 (05:04):
And the delayed sequence intubation is a bit more controlled, but you might not use this if you were unaware about the patient’s NPO status or if they were high risk of aspiration. You might be careful doing that as well.
Speaker 3 (05:16):
You have the luxury to bag because you probably won’t lead to an aspiration event.
Speaker 1 (05:21):
Speaker 2 (05:22):
Okay. Well fantastic. So moving forward, do you want to get right into a case?
Speaker 4 (05:26):
So for our case today, we have a 13 year old male who’s 35 kilos and a history of hemoglobin SS disease that is being admitted to the ICU for concern for acute chest syndrome and progressing into acute respiratory failure. He’s currently being treated with plasma exchange and during that process he becomes more agitated and altered and develops increased work of breathing with tachypnea and lower saturations while on a hundred percent oxygen on high flow nasal cannula. The decision is made to emergently intubate the patient due to concern for acute hypoxic and hypercarbic respiratory failure and inability to protect his airway due to altered mental status. So as a first provider in the room, when I hear this type of scenario or I’m assessing the patient and I’m thinking, okay, I think we going to have to go ahead and put in an advanced airway in. I have to think, Leslie, we discussed just recently do I have to do rapid sequence or delayed sequence? And the biggest thing is am I going to have time to put the airway in? Is he at higher risk for arresting and what’s this patient’s NPO time been? Those are some factors that affect my decision in terms of how I’m going to approach this patient.
Speaker 1 (06:38):
I 100% agree that you’re going to take your patient’s clinical presentation into consideration for how you’re going to approach their airway. So based on our discussion from our earlier podcast, we’ve determined that based on his age and size, we can probably utilize a 6.5 micro cuffed endotracheal tube. And based on his size, I might choose a MAC three to facilitate intubation. And while we’re getting that stuff ready, the pharmacist reach out and says, Hey, what do you want for meds? This is what I think I’m doing, but I want to know what you want. So when you’re considering a medication approach to any patient, what you want to make sure is that you have the ability to cover any pain they might experience. So that’s kind of your analgesic. You want to make sure that they don’t remember going through that dramatic process. So you want an amnestic and then plus or minus a paralytic.
So I would say 90% of the time you’re going to want a paralytic, but there are clear contraindications to paralyzing a patient. And so knowing what those are. The other alternative is to use what we would consider in our institution a general anesthetic. And so those medications include ketamine or propofol plus a paralytic. And so we can talk about those in a little bit more detail as we work through this case. And then the last piece to consider is this opportunity for premedication and what those pre-medications might be and what might be the opportunity. So Gina, you have now gotten intimate with this case scenario. Tell me what you think is the best medication choice and why did you choose these medications?
other aspects that I also look at in terms of the clinical scenario for the patient in terms of what kind of medications I’m going to give them prior to intubation include their hemodynamics because a lot of your sedatives will affect your hemodynamics. So I know we talked about will I be able to protect their airway or ventilate and oxygenate them without any patient effort. I think that’s another thing that will also help guide whether or not to use a paralytic yes or no. But the patient’s hemodynamics will really determine what kind of sedation I will choose to use. And so for this case scenario, the patient is hypertensive and tachycardic due to his distress. So given that my hemodynamics are generous and could potentially change once I alter his cardiopulmonary interactions by intubating him, I’ll have to keep that in mind. But right now he doesn’t appear to be septic.
And so for him, I would probably lean towards a rapid sequence intubation. And so I would want to choose a sedative that is a quick on sedative. And so I can either use a fentanyl dose that two micrograms per kilo or a decent sedation that you can use is ketamine as well. But I probably lean towards using fentanyl in this scenario and then I wouldn’t, because of his generous blood pressure, I probably wouldn’t mind using a half dose of Versed or he could even use a full dose of Versed. And then I would probably use rocuronium for my muscular blockade and just do RSI. So I would give each medication back to back and then flush at the very end.
Speaker 2 (09:56):
So when thinking about delivering a medication for these patients, so you got to have analgesic, you got to have an amnestic or a sedative and then a neuromuscular blockade. So for this case you were saying fentanyl would be your analgesic, your amnestic would be Versed, and then your neuromuscular block would be rocuronium. Is that correct?
Speaker 4 (10:14):
Speaker 2 (10:15):
And because he was a little bit hypertensive, you weren’t so concerned that he would have a cardiac arrest by giving these sedatives prior to intubation?
Speaker 4 (10:25):
Yes, there was definitely room to give him these sedatives. He could still become hypotensive, but he wasn’t starting off hypotensive prior to the procedure. But I would still anticipate that he could potentially become hypotensive as well if he was getting hypercapnic. So just keeping in mind that your hemodynamics can change as you’re in the process of getting ready to intubate the patient
Speaker 2 (10:48):
With him already being somewhat altered, does that change how you would dose your sedation medicine
Speaker 4 (10:53):
For the fentanyl? Because I know it’s not going to have as much a hemodynamic effect, I would still likely give two per kilo to effectively sedate the patient and for the Versed that I would actually maybe consider using a half dose, 0.05 per kilo. And you can always give more on top of that if you need. So you can always start off a little bit lower, and if it’s not enough, you can have, especially that’s the advantage of having pharmacy at bedside is that they can always have additional doses ready to give and rocuronium, just making sure if you’re going to paralyze, go ahead and give the full dose as long as you know you’re able to support the airway.
Speaker 1 (11:29):
Yeah, no, I think you bring up some good points. So one of the questions that you brought up, Zach, was a little bit of a loaded question based on their mental status. So in the adult world, some people will say if they’re completely unresponsive, I’m just going to intubate ’em without giving them any drugs. I would say in the pediatric realm, I’ve not seen that approach taken. I have seen the instance in which a provider will just give a dose of a paralytic and say, oh yeah, they were non-responsive, so I didn’t give them anything. I would really advise to avoid that strategy and really be certain to still provide at least some pain control and some amnesia for that patient because we really don’t know what these patients are experiencing and I think it’s important to cover them. And then the other caveat that I would just say, just like Gina said, I think the two micrograms per kilo of fentanyl is a great dose to start at.
I’m of the school to do a little bit more and to continue to add versus kind of starting big. I’ve had some faculty members that would say, oh, I’ll just start with five per kilo of fentanyl. That’s fine. And I don’t take that approach. I would rather do two per kilo and if they need another two per kilo dose than give ’em another two per kilo dose. And so that’s generally how I would approach that. And then I would agree with Gina, this kiddo’s hemodynamics seems stable and seem appropriate. There are some confounding factors that have been included in the case scenario that may impact what happens when you intubate or while you’re changing medications around. And that’s the fact that the kids on plasma exchange, so plasma exchange in itself, depending on what they’re getting in their kind of return volume can cause significant electrolyte abnormalities, which could potentially result in hypotension or dysrhythmias. And so knowing that piece of the case, I might ask my pharmacist, Hey, could you have an extra dose of calcium chloride available? Have a dose of epi that’s available, and then consider some fluid as well because that piece can contribute to when you’re getting ready to intubate for this kiddo.
Speaker 2 (13:32):
And I didn’t even pick up on that, the requirement for needed electrolytes.
Speaker 1 (13:37):
Yeah, so I think the fentanyl Versed rocuronium approach is the standard approach that we use in our ICU at Children’s Mercy for straightforward intubations. As we have gotten providers that have trained from other institutions, we’ve seen additional approaches being taken. And so one of my partners really likes using ketamine as their induction agent, and I think it’s fantastic. So what do you guys think is a great advantage of utilizing ketamine versus kind of doing this fentanyl Versed approach as your induction agent?
Speaker 3 (14:09):
So ketamine will, my understanding is that if you have adrenal reserve, it’ll raise your blood pressure slightly, and so it supports your hemodynamics unless it’s a kid that’s been very sick for a very long time and you don’t want to use it in a kid who has a brain because it’ll increase their ICP is sort of the way that I was thinking about it. I don’t know if this kid, you considered so sick that you were trying to avoid ketamine.
Yeah, so I think that brings up a good point. So in this setting of kind of adrenal fatigue or somebody who’s been sick for a long time, because ketamine releases your endogenous catecholamines, when you don’t have those endogenous catecholamines released, it can lead to hypotension and potentially cardiac arrest. And so knowing your clinical scenario of your patient is helpful. The other piece is it can cause pretty profound hypertension. And so if you have somebody who is already hypertensive to begin with, it may not be the best option because you don’t want to cause harm to their cerebral vasculature in the setting of being pretty profoundly hypertensive. And so that may be another reason not to give it. We had a kid recently in the unit who kind of rode on being at that hypertensive level and oftentimes we’re like, oh, ketamine would be a great choice, but his systolic blood pressure is already 150. I’ll use something else. But then that might give you an opportunity to use something like propofol as your induction agent. And so what would be a good advantage of a propofol?
Speaker 2 (15:33):
When I think of propofol, I feel like that slows everything down. It maybe brings the blood pressure a little bit down. If you’re worried about intra cerebral pressure, I bring that down. I think of it more as a sedative than an analgesic. So it might want to pair it with something else as well.
Speaker 1 (15:49):
Yeah, exactly. So ketamine will be able to give you your analgesia and your amnestic quality, whereas propofol really doesn’t. It’s really just primarily a sedative. And so you probably want to add something in. And so oftentimes what we’ll see is something called KE fall where people will do a little bit of propofol and a little bit of ketamine with the neuromuscular blockade, and then you’ve got a good combination that covers your analgesic, your amnesia, and your neuromuscular blockade.
Speaker 4 (16:15):
I also really like propofol. It’s quick on, quick off. And so if I know that the patient is going to tolerate it from a hemodynamic standpoint, I think that’s the initial thing with bolusing propofol is you have an acute drop in your SVR. And so if I know that the patient will likely tolerate that initial drop in their hemodynamics, then I like to use it because if I cannot support their airway, then I know that the propofol will be metabolized and out of their system fairly quickly and that they can go back to spontaneously breathing. So that’s also another reason why I like propofol is in those scenarios where I can have that as my backup, the rapid metabolism of propofol.
Speaker 2 (16:58):
So a couple of key take home points. We’ve already said ketamine, it’s a little bit different than our other agents. You can get some analgesia and sedation because it’s dissociative. On the other hand, propofol is more of just a sedation medicine as opposed, it’s not really analgesic at all. The other part is the hemodynamics. They think of ketamine as something that typically makes the blood pressure increase. And on the other hand, propofol tends to make everything kind go a little bit lower. So the lower blood pressure,
Speaker 1 (17:28):
Exactly. There’s one other drug that kind of fits in that category of being that general anesthetic or general induction agent, and that’s etomidate in our institution. Etomidate is used really frequently down in the emergency department for intubations. I would say in my training and in the time that I’ve been an attending, I’ve really only utilized accommodate on one occasion. So what are some of the advantages of etomidate?
Speaker 2 (17:55):
So when I think about etomidate, I just think of traumatic brain injury and kind of being cerebral protective.
Speaker 1 (18:01):
Yeah. So the nice thing about etomidate is you maintain your hemodynamics and you do get both the amnestic quality and the analgesic quality. So you can use it as a single agent and then you just add the paralytic to it. The downfall of etomidate is that it’s been shown to cause adrenal suppression with just one dose. And so it should be avoided in your septic patients because you can have that adrenal suppression be really influential in their course later on after they get intubated.
Speaker 3 (18:39):
And thank you for listening to this episode of PedsCrit. Please remember that everything discussed is intended for informational and educational purposes only. It should not be used as a replacement for medical advice. The views expressed during this episode by hosts and our guests are also their own and do not reflect the official positions of their institutions. If you have any comments, suggestions, or feedback, you can email us at peds crit firstname.lastname@example.org. You can also check out peds crit.com for detailed show notes and visit at crit peds on Twitter and at peds crit on Instagram for realtime show updates. Thank you again for listening.