When to Intubate the Critically Ill Child

The critically ill child is an uncommon patient outside of pediatric tertiary care centers. However, any physician who cares for pediatric patients in an office or in a community hospital setting may be responsible for the initial diagnosis and stabilization of a critically ill child while arrangements are made to transfer the patient to a pediatric intensive care unit.   Adult intensivists Rebecca Appelboam and Bruce McCormick, in their article, discusses when to intubate the critically ill child. (1)

“Sedation and intubation forms an integral part of the overall management of the critically ill child as well as simultaneous attention to all aspects of resuscitation, including fluid management.

“Sedation, intubation and ventilation may be indicated for children with airway pathology, airway compromise due to impaired consciousness or for respiratory failure. In addition, haemodynamic compromise that has failed to respond to fluid resuscitation is itself an indication for intubation and ventilation – up to 40% of a sick child’s cardiac output may be required to support its work of breathing.“[Emphasis added. Also begin catecholamine support when the patient has failed to respond to adequate fluid challenge. And do it before (if possible) RSI which may in itself drop the pressure.]

“We should be aware that recent guidance suggests that initial fluid resuscitation in children with haemodynamic compromise, should occur rapidly  –  i.e.  within  the  first  15  minutes from presentation. Intubation  and  ventilation  also  aids  safe  insertion  of  invasive  monitoring  in  critically  ill coagulopathic children with severe sepsis.”

The author of the above also makes two other excellent recommendations:

“If intubation is planned, you should have the best available help with you. Where possible, induction and intubation of a sick child in a district hospital should be undertaken by two consultant anaesthetists/intensivists. It is advisable to ask your colleague on-call for the anaesthesia team to assist, no matter what their paediatric experience. The presence of an operating department practitioner (ODP) or an experienced ICU nurse is also invaluable. [These colleagues provide  extra hands, additional knowledge and experience, and moral support].

Also remember, she advises, to obtain help from relevant specialists; for example, an ENT specialist when airway compromise is present.

(1) Intubation for Sick Children–Practical Tips for Adult Intensivists, ANAESTHESIA TUTORIAL OF THE WEEK 169, 8TH FEBRUARY 2010. Rebecca Appelboam,Derriford Hospital, Plymouth. Bruce McCormick, Royal Devon and Exeter NHS Foundation Trust

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