Dr. Horeczko’s site is the Pediatric Playbook. In his outstanding podcast and show notes, [Pediatric] Adventures In RSI Nov 2015, Dr. Horeczko discusses RSI in four different cases: sepsis, multitrama, cardiogenic shock, and status epilepticus. I did a summary post, Pediatric Rapid Sequence Intubation – Awesome Podcast From Dr. Horeczko October 30, 2016.
Over the next few days, I’m going to make a seperate post on each of his cases. This will help me in my review and will make the information easier to find when I need it.
Case 1: Sepsis
Laura is a 2-month-old baby girl born at 32 weeks gestational age who today has been “breathing fast” per mother. On arrival she is in severe respiratory distress with nasal flaring and intercostal retractions. Her heart rate is 160, RR 50, oxygen saturation is 88% on RA. She has fine tissue-paper like rales throughout her lung fields. Despite a trial of a bronchodilator, supplemental oxygen, even nasal CPAP and fluids, she becomes less responsive and her heart rate begins to drop relatively in the 80s to 90s – this is not a sign of improvement, but of impending cardiovascular collapse.
She is in respiratory failure from bronchiolitis and likely viral sepsis. She needs her airway taken over.
Is this child stable enough for intubation?
Summarizing – Case 1 from 0 to 23:30 is about a 2 month old with bronchiolitis and likely viral sepsis who is in impending cardiovascular collapse. She is in respiratory failure and she needs her airway taken over but is she stable enough for intubation? Dr. Horeczko states “We have a few minutes to optimize, to resuscitate before we intubate.” [We remember that RSI in an unstable patient can lead to cardiovascular collapse. So we will give this patient fluid boluses and if forced to intubate before fluid boluses have improved the MAP sufficiently we will give a push dose pressor.]
For information on pediatric pulse dose pressors, see Another Great YouTube Video from Dr. Mellick–Pediatric Pulse Dose Pressor Administration Posted on October 2, 2014 by Tom Wade MD.
Tip for getting the fluid bolus in as rapidly as possible:
Here’s an easy tip: use the sterile flushes in your IV cart and push in 20, 40, or 60 mL/kg NS. Just keep track of the number of syringes you use – it is the fastest way to get a meaningful bolus in a small child.
Induction Agent In Sepsis:
The consensus recommendation for the induction agent of choice for sepsis in children is ketamine.
Etomidate is perfectly acceptable, but ketamine is actually a superior drug to etomidate in the rapid sequence intubation of children in septic shock. It [ketamine] rapidly provides sedation and analgesia, and supports hemodynamic stability by blocking the reuptake of catecholamines.
Ketamine is the only drug used in RSI that is dosed on ideal body weight. Keep that in mind when you dose the larger children and adults. This is in contrast to the other RSI medicines that we use where we dose on total body weight.
We preoxygenate our little two month old Laura. She’s positioned appropriately with a towel roll under her scapulae.
Should we use succinylcholine or rocuronium as our paralytic?
Among the problems with succinylcholine are:
- Raises serum potassium in everyone, typically 0.5 to 1 mEq/L. That is not usually a problem, but for those with preexisting or inducible hyperkalemia, it can precipitate an arrest, as in renal failure, underlying neurologic or myopathic conditions like multiple sclerosis, muscular dystrophy, ALS, or those who had a stroke or a burn more than 72 hours prior. We often have limited information in critical situations.
- Succinylcholine gives us a false sense of security. In children, there really is no “safe apnea” period.
“Rocuronium has none of the problems of succinylcholine,” Dr. Horeczki states.
At 0.6 mg/kg, rocuronium is inferior to succinylcholine at all time intervals. At 1.0 mg/kg, rocuronium is still inferior at 45 seconds. 1.2 mg/kg rocuronium is the dose now commonly recommended; per a study by Heier et al. in Anesthesia and Analgesia in 2000, rocuronium produced excellent intubating conditions in higher doses.
We do not take away that which we cannot give back. [In other words, the shorter duration of action of succinylcholine as compared to rocuronium is not a meaningful advantage]
We paralyze and we need to keep our eyes on that prize. We need to get that definitive airway in by hook or by scalpel, finger, bougie? – Okay maybe not a very small children but a nice rescue device that is underutilized – is our friend the LMA which comes in all sizes all the way down to premie.
Luckily, you prepare everything well.
She gets a dose of atropine because she is less than one year of age. You use a Miller one blade, a size 3.5 cuffed ET tube, and you successfully intubate her and continue your resuscitation.
As this is only day one of her illness, her bronchiolitis is likely to only worsen. Hopefully we see a nice recovery and a weaning off of the ventilator.
At the end of his podcast, Dr. Horeczko summaries his talk as follows:
In summary, in these cases of sepsis, multitrauma, cardiogenic shock, and status epilepticus:
- Resuscitate before you intubate
- Use the agent’s specific properties and talents to your benefit
- Adjust the dose in critically ill patients: decrease the sedative, increase the paralytic
- Have post-intubation care ready: analgesia, sedation, verification, NG/OG/foley
