The safety of etomidate for emergency rapid sequence intubation of pediatric patients

Predicting adverse outcomes in a diagnosis-based protocol system for rapid sequence intubation

Our ED at Louisiana State University developed a unique approach to airway management by having four diagnosis-based protocols for rapid sequence intubation (RSI). This study examines protocol use and outcome from RSI in an academic ED. The study objective was to identify variables that are predictive of adverse outcomes in patients requiring RSI. This was a 4-year prospective, observational, data-gathering study of all intubations in an academic ED setting with >250,000 patient visits per year. Four protocols were established for 1) children <10 years of age, 2) adults with increased intracranial pressure, 3) adults with chronic obstructive pulmonary disease/asthma, and 4) other adults not fitting B or C. A special continuing quality improvement (CQI) committee was established to examine each case of RSI. Prospective data were collected, including age, race, gender, protocol, diagnostic group, intubation indication, and preintubation oxygen saturation. Diagnostic group was categorized as medical, blunt trauma, or penetrating trauma. Adverse outcome was defined as any case with hemodynamic changes, those requiring surgical or bronchoscopic intervention, and those requiring more than three attempts at intubation. Data were analyzed using univariate analysis, logistic regression, and a binomial regression tree analysis with SPSS 9.0 (Chicago, IL) and Answer Tree (SPSS). A total of 1,320 consecutive intubated patients were included. Protocol A was used in 4%, B in 43%, C in 15%, and D in 38%. Significant differences in number of cases with adverse outcome were based on protocol (P =.03) and final diagnosis (P <.03). Protocol C was less likely to be associated with adverse outcome than protocol D (odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1-0.7). Penetrating trauma was more likely to be associated with adverse outcome (OR = 1.8, 95%, CI = 1.1-3.2) than blunt trauma. A regression tree analysis yielded the following, all cases using protocol A or C or medical cases using B had an adverse event in 11 of 458 (2.4%), whereas nonmedical cases using protocols B or D and medical cases using D had adverse outcomes in 73 of 862 cases (8.5%). The decision rules lead to a better classification of cases with adverse outcomes (2.4 vs 8.5%, of = 6.1%, 95% CI = 3.7-8.4). Adult trauma patients who fit the protocols B or D or adult medical patients who fit protocol B were at higher risk for adverse outcomes with RSI. This could alert the physician to a population at higher risk for adverse outcomes. Variables available in a diagnosis-based protocol RSI system can be used to predict adverse outcome among patients requiring RSI.

Rapid sequence intubation for pediatric emergency airway management

OBJECTIVES

To characterize current practice with respect to pediatric emergency airway management using a multicenter data set.

METHODS

A multicenter collaboration was undertaken to gather data prospectively regarding emergency intubation. Analysis of data on adult emergency department (ED) intubations clearly demonstrated that rapid sequence intubation (RSI) was the method used most often. We then conducted an observational study of the prospectively collected database of pediatric ED intubations (EDIs) using the National Emergency Airway Registry Phase One data, gathered in 11 participating EDs over a 16-month time period. A data form completed at the time of EDI enabled analysis of patients' ages, weights, and indications for EDI; personnel; methods employed to facilitate EDI; success rates; and adverse events. Data forms were analyzed regarding the methods of intubation employed, and frequencies, success rates, and adverse event rates among various intubation modalities were compared.

RESULTS

Of 1288 EDIs, there were 156 documented pediatric patients. Initial intubation attempts were all oral, including rapid sequence intubation in 81%, without medications (NOM) in 13%, and sedation without neuromuscular blockade (SED) in 6%. Older children and trauma patients were more likely to be intubated with RSI compared to younger children and patients presenting with medical illnesses. Intubation using RSI was more successful on the first attempt (78%) compared with either NOM (47%, < 0.01) or SED (44%, < 0.05), though this finding is likely explainable by the age differences among groups. Intubation was successfully performed by the initial intubator in 85% of RSI, 75% of NOM, and 89% of SED attempts ( = NS for both comparisons vs RSI). Overall, successful intubation occurred in 99% of RSI and 97% of non-RSI intubation attempts ( = NS). Only one of 156 patients required surgical airway management. True complications occurred in 1%, 5%, and 0% of RSI, NOM, and SED attempts, respectively ( = NS for both comparisons vs RSI). The majority of initial intubation attempts were by emergency medicine residents (59%), pediatric emergency medicine fellows (17%), and pediatrics residents (10%). These groups were 77%, 77%, and 50% successful, respectively, on the first laryngoscopy attempt, and 89%, 89%, and 69% successful overall.

CONCLUSIONS

A large, prospective, multicenter observational study of pediatric EDIs was conducted at university-affiliated EDs. RSI is the method of choice for the majority of pediatric emergency intubations; it is associated with a high success rate and a low rate of serious adverse events. Pediatric intubation as practiced in academic EDs, with most initial attempts by emergency and pediatrics residents and fellows under attending physician supervision, is safe and highly successful.

Etomidate for procedural sedation in emergency medicine

STUDY OBJECTIVE

We describe and analyze the effectiveness and safety of etomidate for procedural sedation and evaluate the patient's perspective on effectiveness, side effects, and satisfaction.

METHODS

We conducted an observational retrospective study of all patients who received etomidate for procedural sedation over 2 years in 3 affiliated suburban emergency departments of a large group-model health maintenance organization. Data were abstracted from the ED records. Additionally, a patient questionnaire was prospectively administered by telephone.

RESULTS

Etomidate was used for sedation in 134 patients between 6 and 93 years of age during 150 procedures. The mean cumulative dose was 0.20 mg/kg. Adjunctive medication was used in 36 (23%) procedures. Moderate sedation with verbal arousability was induced in 48 (32%) patients, and deep sedation with verbal unresponsiveness was induced in 102 (68%) patients. Full recovery to the preprocedural level of alertness was achieved within 30 minutes in 142 (95%) of procedures. Mean changes in systolic blood pressure, pulse rate, and oxygen saturation were clinically insignificant. There were 7 (4.7%; 95% confidence interval [CI] 1.9% to 9.4%) adverse events, including 5 (3.3%; 95% CI 1.1% to 7.6%) cases of oxygen desaturation below 94% in older patients (>55 years of age) who received slightly higher mean doses of etomidate (0.23 mg/kg). Four of these patients received brief assisted bag-valve-mask ventilation and recovered uneventfully; none required endotracheal intubation. The questionnaire was completed by 120 (90%) of 134 patients and involved 136 procedures. During 127 (93%) of these, etomidate was believed to be extremely effective in causing sleep, and for 127 (93%) it induced complete procedural amnesia. Only 5 (4%) patients experienced nausea or vomiting. Regarding willingness to receive etomidate for their next procedure, the patients' responses were favorable: extremely, 95%; moderately, 2%; slightly, 3%; and not at all, 1%.

CONCLUSION

Etomidate is a useful agent for carefully conducted procedural sedation because it provides effective, brief, deep sedation with little hemodynamic compromise. Its safety may be jeopardized by the occurrence of respiratory depression in older patients receiving higher doses. Patients report a high degree of satisfaction with etomidate.

Etomidate for procedural sedation in the emergency department

STUDY OBJECTIVE

To review our experience with etomidate in nonintubated patients in the emergency department.

DESIGN

A 2-year retrospective chart review of consecutive patients receiving etomidate for sedation.

SETTING

Emergency department of a university-based teaching hospital.

PATIENTS

Forty-eight patients who underwent painful procedures in the emergency department.

MEASUREMENTS AND MAIN RESULTS

Demographics, dosing information, recovery times, and adverse events were abstracted using a standardized data collection form. Forty-eight nonintubated patients were sedated with etomidate. Mean age was 34 years (range 6-80 yrs); 38 were men and 10 women; two were children. The mean initial dose of etomidate was 13 mg. Adverse events occurred in 11 (21%) patients. None sustained any substantial morbidity as indicated by need for intubation, prolonged emergency department stay, or hospital admission.

CONCLUSION

Although controversial, etomidate holds promise as a potent sedative agent for patients undergoing painful procedures in the emergency department. A large prospective evaluation is needed to document the performance and complications of this agent.

Contemporary trends in pediatric sedation and analgesia

The ability to provide safe, effective procedural sedation and analgesia is a necessary skill for physicians caring for the acutely ill or injured pediatric patient. They physician should be familiar with the agent(s) chosen, including dosage, duration, adverse effects, and contraindications. The choice of agent and regimen should be individualized for the patient and situation. Successful outcomes depend on performing careful pre- and post-sedation evaluations, following appropriate monitoring and equipment guidelines, and having the knowledge and skills to manage any adverse cardiorespiratory event.

Pediatric neurologic emergencies

Neuroemergencies are life-threatening situations in which, whatever the cause, common pathologic phenomena result in secondary brain lesions. The goal of critical care management is to stop these self-aggravating processes as soon as possible. Initial resuscitation is devoted to control of the airway and hemodynamic and hydroelectrolytic stabilization. With mass lesions, minimal computed tomographic exploration immediately precedes surgical decompression. Further critical care adapted to the child's needs requires multimodal monitoring. Normoventilation, deep sedation, osmotherapy with mannitol or hypertonic saline solutions, and optimization of mean arterial pressure are the basis of management. A purely pressure-driven approach aimed at controlling cerebral perfusion pressure could be potentially harmful, and associated measurement of blood flow velocity with transcranial Doppler and jugular bulb oxygen saturation monitoring allows an approach to cerebral blood flow and metabolism. Outcome can be improved in dangerous situations such as severe brain injuries, cerebral arteriovenous malformation rupture, status epilepticus, and acute hydrocephalus, provided that emergency management could be applied efficiently.

Etomidate: applications in pediatric critical care and pediatric anesthesiology

Etomidate is a carboxylated, imidazole-containing intravenous anesthetic agent introduced into clinical anesthesia practice in 1972. Its distinctive features that make it useful as an anesthetic induction include a lack of adverse effects on hemodynamic function as well as beneficial effects on cerebral blood flow and intracranial pressure. Because of these properties, its major role in anesthetic practice has been for the induction of anesthesia in patients with diminished cardiovascular function. As opposed to the considerable reported clinical experience with etomidate in the adult population, there remains limited reported information concerning its use in pediatric patients. This article reviews the specific end-organ effects of etomidate, the reports concerning its use in pediatric patients, and its adverse effect profile.