Dive into the intricacies of pediatric intubation, focusing on the best induction agents for critically ill children. Explore real-world scenarios that underscore the importance of hemodynamic stability during intubation. Discover the roles of various agents like propofol, ketamine, and fentanyl, along with crucial strategies for rapid sequence intubation. Learn about the challenges posed by cardiac dysfunction and how to manage high-risk intubations effectively. This discussion is rich with insights and practical tips for optimizing patient care!
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Avoid Propofol In Cardiac Dysfunction
Avoid propofol for induction in children with cardiogenic shock due to myocardial depression and vasodilation.
Choose short-acting agents that preserve hemodynamics and prepare for peri-arrest support.
insights INSIGHT
Intubation Meds Are A Three-Course Menu
Think of intubation meds as a three-course menu: analgesia, sedation/amnesia, then paralysis.
Tailor each 'course' to clinical context to minimize cardiopulmonary compromise.
volunteer_activism ADVICE
Use Rocuronium For Reliable Paralysis
Use rocuronium for pediatric RSI due to its rapid onset (45–90s) and reliable paralysis.
Wait 45–90 seconds when possible to optimize intubating conditions and first-pass success.
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Learn how to sharpen your pediatric intubation skills and make evidence-based decisions at the bedside. Today, Dr. Pradip Kamat, Dr. Monica Gray, and Dr. Rahul Damania expertly dissect the nuances of selecting optimal induction agents for critically ill children in the PICU. Through engaging, real-world case scenarios, our hosts guide you through drug choices in complex situations such as cardiogenic shock, septic shock, and elevated intracranial pressure—always prioritizing hemodynamic stability and patient safety. Gain valuable insights into the advantages, limitations, and clinical pearls of agents like propofol, fentanyl, ketamine, and midazolam, along with practical strategies for rapid sequence intubation, neuromuscular blockade, and individualized patient care. Don’t miss this high-yield discussion, packed with actionable knowledge!
Show Highlights:
Induction agents for endotracheal intubation in critically ill children
Clinical scenarios highlighting optimal choices of induction agents and neuromuscular blockers
Importance of maintaining hemodynamic stability during intubation
Pharmacology and clinical considerations of various induction agents (e.g., propofol, ketamine, fentanyl, etomidate)
Use of neuromuscular blocking agents (NMBAs) in pediatric intubation
Differences between depolarizing and non-depolarizing neuromuscular blockers
Risks associated with specific induction agents in patients with cardiac dysfunction or septic shock
Modified rapid sequence intubation (RSI) techniques for unstable patients
Key takeaways for managing critically ill pediatric patients requiring intubation
Practical tips for optimizing intubation conditions and minimizing complications
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care 6th Edition. Chapters 127 - 135, Pages 1510 - 1610
Hendrix JM, Regunath H. Intubation Endotracheal Tube Medications. [Updated 2025 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459276/
Agrawal, Dewesh. Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis. UpToDate. Last updated Dec 4, 2024.
Vanlinthout LE, Geniets B, Driessen JJ, Saldien V, Lapré R, Berghmans J, Uwimpuhwe G, Hens N. Neuromuscular-blocking agents for tracheal intubation in pediatric patients (0-12 years): A systematic review and meta-analysis. Paediatr Anaesth. 2020 Apr;30(4):401-414. doi: 10.1111/pan.13806. Epub 2020 Mar 9. PMID: 31887248.
Tarquinio KM, Howell JD, Montgomery V, Turner DA, Hsing DD, Parker MM, Brown CA 3rd, Walls RM, Nadkarni VM, Nishisaki A; National Emergency Airway Registry for Children; Pediatric Acute Lung Injury and Sepsis Investigators Network. Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study. Pediatr Crit Care Med. 2015 Mar;16(3):210-8. doi: 10.1097/PCC.0000000000000319. PMID: 25581629.
Conway JA, Kharayat P, Sanders RC Jr, Nett S, Weiss SL, Edwards LR, Breuer R, Kirby A, Krawiec C, Page-Goertz C, Polikoff L, Turner DA, Shults J, Giuliano JS Jr, Orioles A, Balkandier S, Emeriaud G, Rehder KJ, Kian Boon JL, Shenoi A, Vanderford P, Nuthall G, Lee A, Zeqo J, Parsons SJ, Furlong-Dillard J, Meyer K, Harwayne-Gidansky I, Jung P, Adu-Darko M, Bysani GK, McCarthy MA, Shlomovich M, Toedt-Pingel I, Branca A, Esperanza MC, Al-Subu AM, Pinto M, Tallent S, Shetty R, Thyagarajan S, Ikeyama T, Tarquinio KM, Skippen P, Kasagi M, Howell JD, Nadkarni VM, Nishisaki A; National Emergency Airway Registry for Children (NEAR4KIDS) and for the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Ketamine Use for Tracheal Intubation in Critically Ill Children Is Associated With a Lower Occurrence of Adverse Hemodynamic Events. Crit Care Med. 2020 Jun;48(6):e489-e497. doi: 10.1097/CCM.0000000000004314. PMID: 32317603.
Zanza C, Piccolella F, Racca F, Romenskaya T, Longhitano Y, Franceschi F, Savioli G, Bertozzi G, De Simone S, Cipolloni L, La Russa R. Ketamine in Acute Brain Injury: Current Opinion Following Cerebral Circulation and Electrical Activity. Healthcare (Basel). 2022 Mar 17;10(3):566. doi: 10.3390/healthcare10030566. PMID: 35327044; PMCID: PMC8949520.
Zeiler FA, Teitelbaum J, West M, Gillman LM. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care. 2014 Aug;21(1):163-73. doi: 10.1007/s12028-013-9950-y. PMID: 24515638.
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