Evaluation of rapid sequence intubation in the pediatric emergency department

Abstract

Objectives: To describe the experience of the emergency department of a pediatric hospital with rapid sequence intubation (RSI) and to identify the factors associated with successful intubation.Methods: This prospective, observational, cross-sectional study conducted from July 2005 to December 2007 consisted of collection of data regarding tracheal intubations performed at the emergency department of Instituto da Criança of Hospital das Clínicas, School of Medicine, Universidade de São Paulo. Successful tracheal intubations were the ones performed at the first attempt. Results:One-hundred and seventeen tracheal intubations were performed; 80% of them were RSIs; 79% of patients had underlying diseases; acute respiratory failure was the cause of tracheal intubation in 40%; success rate was 39%; second-year pediatric resident physicians were responsible for 74% of tracheal intubations; positive pressure ventilation was performed in 74% of procedures, with less frequent use among patients who were successfully intubated (p = 0.002). Midazolam was the sedative used in 80% of procedures, and rocuronium was the neuromuscular blocker in 100%; complications of RSI were described in 80% of intubations, with decreased oxygen saturation being reported in 47% and lower decrease in those patients successfully intubated (p < 0.001); difficulties related to tracheal intubation were less frequent in the successful procedures (p < 0.001). Conclusion:RSI is the method of choice for tracheal intubations performed in the emergency department (80%). In spite of the low success rate (39%) in the present study, RSI has proven to be a safe method, with a low incidence of severe complications. The success of tracheal intubation using RSI seems to be directly related to the preparation of the procedure and the health professional's experience. Thus, we conclude that further training of resident physicians and health professionals working in the emergency department is required. J Pediatr (Rio J). 2011;87(4):343-349:Intratracheal intubation, intubation methods, adverse effects of intubation, neuromuscular blockers, emergency treatment, child, laryngoscopy, trachea. ResumoObjetivos: Descrever a experiência do pronto-socorro de um hospital pediátrico com a sequência rápida de intubação e detectar os fatores associados ao sucesso. Resultados: Foram realizadas 117 intubações traqueais, 80% sob sequência rápida de intubação; 79% eram portadores de doenças de base; a insuficiência respiratória aguda foi a causa da intubação traqueal em 40%; a taxa de sucesso foi de 39%; o residente de pediatria do segundo ano foi o responsável por 74% das intubações traqueais; foi realizada ventilação com pressão positiva em 74% dos procedimentos, sendo menor a sua utilização entre os pacientes que foram intubados com sucesso (p = 0,002). Midazolam foi o sedativo utilizado em 80% dos procedimentos, e rocurônio foi o bloqueador neuromuscular em 100%; complicações decorrentes da sequência rápida de intubação foram descritas em 80%, sendo a queda da saturaç...

Advancing emergency airway management practice and research

“…Indeed, the first‐pass success rate in children aged <18 years was 60% (and 50% in children aged <2 years) in Japanese EDs, whereas the rate was 74% in overall ED patients . In other studies, the first‐pass success rates in children varied from 39% to 78% . Furthermore, published works have shown that the intubator's experience plays a major role in first‐pass success in children.…”

Frequency and outcomes of endotracheal intubation in the pediatric emergency department

“…That is, most pediatric ETIs are performed due to respiratory failure, cardiopulmonary arrest, seizure and trauma. 10,15,16 Conversely however, Sagarin et al 7 found that the majority of the patients requiring ETI had presented with status epilepticus, followed by trauma. Due to the fact that adult EM in our institute cares for pediatric trauma patients, there were no trauma patients requiring ETI in our study.…”

“…No effect of comorbidity on outcomes, however, had been noted. 9,16,17 Rapid sequence intubation is defined as the simultaneous administration of a sedative/ analgesic and neuromuscular blocking agent to render the patients rapidly unconscious and/or flaccid; in order to facilitate emergent ETI. [18][19][20] In our study only 19% of intubations was performed using RSI.…”

A Modern and Practical Review of Rapid-Sequence Intubation in Pediatric Emergencies

“…[9][10][11][12][13] One potential explanation for these findings may be that RSI is performed infrequently by individual providers for pediatric patients, including in the ED setting. In a study of RSI in a pediatric ED with more than 90,000 annual visits, endotracheal intubation was performed 147 times in a single year, with 123 of these instances representing RSI.…”