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Carvalho VEDL, Couto TB, Moura BMH, Schvartsman C, Reis AG. Atropine does not prevent hypoxemia and bradycardia in tracheal intubation in the pediatric emergency department: observational study. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2023; 42:e2022220. [PMID: 37937676 PMCID: PMC10627482 DOI: 10.1590/1984-0462/2024/42/2022220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 07/24/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVE The benefit of atropine in pediatric tracheal intubation is not well established. The objective of this study was to evaluate the effect of atropine on the incidence of hypoxemia and bradycardia during tracheal intubations in the pediatric emergency department. METHODS This is a single-center observational study in a tertiary pediatric emergency department. Data were collected on all tracheal intubations in patients from 31 days to incomplete 20 years old, performed between January 2016 and September 2020. Procedures were divided into two groups according to the use or not of atropine as a premedication during intubation. Records with missing data, patients with cardiorespiratory arrest, cyanotic congenital heart diseases, and those with chronic lung diseases with baseline hypoxemia were excluded. The primary outcome was hypoxemia (peripheral oxygen saturation ≤88%), while the secondary outcomes were bradycardia (decrease in heart rate >20% between the maximum and minimum values) and critical bradycardia (heart rate <60 bpm) during intubation procedure. RESULTS A total of 151 tracheal intubations were identified during the study period, of which 126 were eligible. Of those, 77% had complex, chronic underlying diseases. Atropine was administered to 43 (34.1%) patients and was associated with greater odds of hypoxemia in univariable analysis (OR: 2.62; 95%CI 1.15-6.16; p=0.027) but not in multivariable analysis (OR: 2.07; 95%CI 0.42-10.32; p=0.37). Critical bradycardia occurred in only three patients, being two in the atropine group (p=0.26). Bradycardia was analyzed in only 42 procedures. Atropine use was associated with higher odds of bradycardia in multivariable analysis (OR: 11.00; 95%CI 1.3-92.8; p=0.028). CONCLUSIONS Atropine as a premedication in tracheal intubation did not prevent the occurrence of hypoxemia or bradycardia during intubation procedures in pediatric emergency.
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Engstrom K, Brown CS, Mattson AE, Lyons N, Rech MA. Pharmacotherapy optimization for rapid sequence intubation in the emergency department. Am J Emerg Med 2023; 70:19-29. [PMID: 37196592 DOI: 10.1016/j.ajem.2023.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023] Open
Abstract
PURPOSE Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods. SUMMARY There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use. AREAS FOR FUTURE RESEARCH The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.
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Affiliation(s)
- Kellyn Engstrom
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America.
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Alicia E Mattson
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Neal Lyons
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood, IL 60153, United States of America; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, United States of America
| | - Megan A Rech
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood, IL 60153, United States of America; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, United States of America
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Walter‐Nicolet E, Marchand‐Martin L, Guellec I, Biran V, Moktari M, Zana‐Taieb E, Magny J, Desfrère L, Waszak P, Boileau P, Chauvin G, Saint Blanquat L, Borrhomée S, Droutman S, Merhi M, Zupan V, Karoui L, Cimerman P, Carbajal R, Durrmeyer X. Premedication practices for neonatal tracheal intubation: Results from the EPIPPAIN 2 prospective cohort study and comparison with EPIPPAIN 1. PAEDIATRIC AND NEONATAL PAIN 2021; 3:46-58. [PMID: 35547594 PMCID: PMC8975199 DOI: 10.1002/pne2.12048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 11/25/2022]
Abstract
To describe the frequency and nature of premedication practices for neonatal tracheal intubation (TI) in 2011; to identify independent risk factors for the absence of premedication; to compare data with those from 2005 and to confront observed practices with current recommendations. Data concerning TI performed in neonates during the first 14 days of their admission to participating neonatal/pediatric intensive care units were prospectively collected at the bedside. This study was part of the Epidemiology of Procedural Pain in Neonates study (EPIPPAIN 2) conducted in 16 tertiary care units in the region of Paris, France, in 2011. Multivariate analysis was used to identify factors associated with premedication use and multilevel analysis to identify center effect. Results were compared with those of the EPIPPAIN 1 study, conducted in 2005 with a similar design, and to a current guidance for the clinician for this procedure. One hundred and twenty‐one intubations carried out in 121 patients were analyzed. The specific premedication rate was 47% and drugs used included mainly propofol (26%), sufentanil (24%), and ketamine (12%). Three factors were associated with the use of a specific premedication: nonemergent TI (Odds ratio (OR) [95% CI]: 5.3 [1.49‐20.80]), existence of a specific written protocol in the ward (OR [95% CI]:4.80 [2.12‐11.57]), and the absence of a nonspecific concurrent analgesia infusion before TI (OR [95% CI]: 3.41 [1.46‐8.45]). No center effect was observed. The specific premedication rate was lower than the 56% rate observed in 2005. The drugs used were more homogenous and consistent with the current recommendations than in 2005, especially in centers with a specific written protocol. Premedication use prior to neonatal TI was low, even for nonemergent procedures. Scientific consensus, implementation of international or national recommendations, and local written protocols are urgently needed to improve premedication practices for neonatal intubation.
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Affiliation(s)
- Elizabeth Walter‐Nicolet
- Medicine and Neonatal Intensive Care Unit Saint Joseph Hospital Paris France
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
| | - Laetitia Marchand‐Martin
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
| | - Isabelle Guellec
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Paediatric and Neonatal Intensive Care Unit, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
- Medicine Sorbonne University Paris France
| | - Valérie Biran
- Neonatal Intensive Care Unit Assistance Publique – Hôpitaux de Paris CHU Robert Debré University Paris Diderot, Sorbonne Paris Cité Paris France
- Inserm U1141 University Paris Diderot, Sorbonne Paris Cité Paris France
| | - Mostafa Moktari
- Pediatric and Neonatal Intensive Care Unit Bicêtre Hospital Assistance Publique – Hôpitaux de Paris Paris France
- Espace Ethique/Ile de France ‐ Saint‐Louis Hospital Assistance Publique ‐Hôpitaux de Paris Paris France
| | - Elodie Zana‐Taieb
- Port‐Royal Maternity Neonatal Intensive Care Unit Cochin‐Port Royal Hospital Assistance Publique‐Hôpitaux de Paris Paris France
| | - Jean‐François Magny
- Neonatal Intensive Care Unit Necker‐Enfants Maladies Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Luc Desfrère
- Neonatal Intensive Care Unit Louis Mourier Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Paul Waszak
- Medicine and Neonatal Intensive Care Unit Delafontaine Hospital Saint Denis France
| | - Pascal Boileau
- Neonatal Intensive Care Unit Centre Hospitalier Intercommunal Poissy‐Saint Germain Poissy France
- Inserm U1185 Université Paris Saclay Le Kremlin‐Bicêtre France
| | - Gilles Chauvin
- Neonatal Intensive Care Unit Argenteuil Hospital Argenteuil France
| | - Laure Saint Blanquat
- Pediatric and Neonatal Intensive Care Unit Necker‐enfants Malades Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | | | - Stéphanie Droutman
- Pediatric and Neonatal Intensive Care Unit Centre Hospitalier Intercommunal André Grégoire Montreuil France
| | - Mona Merhi
- Neonatal Intensive Care Unit Centre Hospitalier Sud Francilien Corbeil‐Essonnes France
| | - Véronique Zupan
- Neonatal Intensive Care Unit Antoine Béclère Hospital Assistance Publique – Hôpitaux de Paris Clamart France
| | - Leila Karoui
- Neonatal Intensive Care Unit, Grand hôpital de l’Est francilien, site de Meaux Meaux France
| | - Patricia Cimerman
- Centre National de Ressources de lutte contre la Douleur, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Ricardo Carbajal
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Medicine Sorbonne University Paris France
- Paediatric Emergency Department, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Xavier Durrmeyer
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Neonatal Intensive Care Unit Centre Hospitalier Intercommunal de Créteil University Paris Est Créteil Créteil France
- Faculté de Médecine de Créteil IMRB, GRC CARMAS Université Paris Est Créteil Créteil France
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Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants. Anesthesiology 2019; 131:830-839. [DOI: 10.1097/aln.0000000000002847] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
The infant airway is particularly vulnerable to trauma from repeated laryngoscopy attempts. Complications associated with elective tracheal intubations in anesthetized infants may be underappreciated. We conducted this study of anesthetized infants to determine the incidence of multiple laryngoscopy attempts during routine tracheal intubation and assess the association of laryngoscopy attempts with hypoxemia and bradycardia.
Methods
We conducted a retrospective cross-sectional cohort study of anesthetized infants (age less than or equal to 12 months) who underwent direct laryngoscopy for oral endotracheal intubation between January 24, 2015, and August 1, 2016. We excluded patients with a history of difficult intubation and emergency procedures. Our primary outcome was the incidence of hypoxemia or bradycardia during induction of anesthesia. We evaluated the relationship between laryngoscopy attempts and our primary outcome, adjusting for age, weight, American Society of Anesthesiologists status, staffing model, and encounter location.
Results
A total of 1,341 patients met our inclusion criteria, and 16% (n = 208) had multiple laryngoscopy attempts. The incidence of hypoxemia was 35% (n = 469) and bradycardia was 8.9% (n = 119). Hypoxemia and bradycardia occurred in 3.7% (n = 50) of patients. Multiple laryngoscopy attempts were associated with an increased risk of hypoxemia (adjusted odds ratio: 1.78, 95% CI: 1.30 to 2.43, P < 0.001). There was no association between multiple laryngoscopy attempts and bradycardia (adjusted odds ratio: 1.23, 95% CI: 0.74 to 2.03, P = 0.255).
Conclusions
In a quaternary academic center, healthy infants undergoing routine tracheal intubations had a high incidence of multiple laryngoscopy attempts and associated hypoxemia episodes.
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Jung KT, Kim HJ, Choi YJ, Hur DK, Kang JH, An TH. Effects of thiopental sodium, ketamine, and propofol on the onset time of rocuronium in children. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.1.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, Gwangju, Korea
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Korea
| | - Hye Ji Kim
- Department of Anesthesiology and Pain Medicine, Gwangju Daejung Hospital, Gwangju, Korea
| | - Yong Joon Choi
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Korea
| | - Dong-ki Hur
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jun Hong Kang
- Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Busan, Korea
| | - Tae Hun An
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, Gwangju, Korea
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Korea
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Wilmott AR, Thompson GC, Lang E, Powelson S, Wakai A, Vandermeer B, O'Sullivan R. Atropine therapy versus no atropine therapy for the prevention of adverse events in paediatric patients undergoing intubation. Hippokratia 2014. [DOI: 10.1002/14651858.cd010898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ashlea R Wilmott
- University of Calgary; Department of Emergency Medicine; Room C231, 1403-29 Street NW Calgary Canada T2N 2T9
| | - Graham C Thompson
- Alberta Children's Hospital, University of Calgary; Department of Paediatrics; 2888 Shaganappi Trail NW Calgary Canada T3B 6A8
| | - Eddy Lang
- University of Calgary; Department of Emergency Medicine; Room C231, 1403-29 Street NW Calgary Canada T2N 2T9
| | - Susan Powelson
- University of Calgary; Health Sciences Libraries and Cultural Resources; HSC 1489, 3330 Hospital Dr. NW Calgary Canada T2N 4N1
| | - Abel Wakai
- Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland; Emergency Care Research Unit (ECRU); 123 St. Stephen's Green Dublin 2 Ireland
| | - Ben Vandermeer
- University of Alberta; Department of Pediatrics; 4-496B Edmonton Clinic Health Academy (ECHA) 11405 - 87 Avenue Edmonton Alberta Canada T6G 1C9
| | - Ronan O'Sullivan
- Our Lady's Children's Hospital Crumlin; National Children's Research Centre; Dublin Ireland 12
- Cork University Hospital; Cork Ireland
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Neuhaus D, Schmitz A, Gerber A, Weiss M. Controlled rapid sequence induction and intubation - an analysis of 1001 children. Paediatr Anaesth 2013; 23:734-40. [PMID: 23763293 DOI: 10.1111/pan.12213] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Classic rapid sequence induction puts pediatric patients at risk of cardiorespiratory deterioration and traumatic intubation due to their reduced apnea tolerance and related shortened intubation time. A 'controlled' rapid sequence induction and intubation technique (cRSII) with gentle facemask ventilation prior to intubation may be a safer and more appropriate approach in pediatric patients. The aim of this study was to analyze the benefits and complications of cRSII in a large cohort. METHODS Retrospective cohort analysis of all patients undergoing cRSII according to a standardized institutional protocol between 2007 and 2011 in a tertiary pediatric hospital. By means of an electronic patient data management system, vital sign data were reviewed for cardiorespiratory parameters, intubation conditions, general adverse respiratory events, and general anesthesia parameters. RESULTS A total of 1001 patients with cRSII were analyzed. Moderate hypoxemia (SpO2 80-89%) during cRSII occurred in 0.5% (n = 5) and severe hypoxemia (SpO2 <80%) in 0.3% of patients (n = 3). None of these patients developed bradycardia or hypotension. Overall, one single gastric regurgitation was observed (0.1%), but no pulmonary aspiration could be detected. Intubation was documented as 'difficult' in two patients with expected (0.2%) and in three patients with unexpected difficult intubation (0.3%). The further course of anesthesia as well as respiratory conditions after extubation did not reveal evidence of 'silent aspiration' during cRSII. CONCLUSION Controlled RSII with gentle facemask ventilation prior to intubation supports stable cardiorespiratory conditions for securing the airway in children with an expected or suspected full stomach. Pulmonary aspiration does not seem to be significantly increased.
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Affiliation(s)
- Diego Neuhaus
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.
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The effect of atropine on rhythm and conduction disturbances during 322 critical care intubations. Pediatr Crit Care Med 2013; 14:e289-97. [PMID: 23689705 DOI: 10.1097/pcc.0b013e31828a8624] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Our objectives were to describe the prevalence of arrhythmia and conduction abnormalities before critical care intubation and to test the hypothesis that atropine had no effect on their prevalence during intubation. DESIGN Prospective, observational study. SETTING PICU and pediatric/neonatal intensive care transport. SUBJECTS All children of age less than 8 years intubated September 2007-2009. Subgroups of intubations with and without atropine were analyzed. INTERVENTION None. MEASUREMENT AND MAIN RESULTS A total of 414 intubations were performed in the study period of which 327 were available for analysis (79%). Five children (1.5%) had arrhythmias prior to intubation and were excluded from the atropine analysis. Atropine was used in 47% (152/322) of intubations and resulted in significant acceleration of heart rate without provoking ventricular arrhythmias. New arrhythmias during intubation were related to bradycardia and were less common with atropine use (odds ratio, 0.14 [95% CI, 0.06-0.35], p < 0.001). The most common new arrhythmia was junctional rhythm. Acute bundle branch block was observed during three intubations; one Mobitz type 2 rhythm and five ventricular escape rhythms occurred in the no-atropine group (n = 170). Only one ventricular escape rhythm occurred in the atropine group (n = 152) in a child with an abnormal heart. One child died during intubation who had not received atropine. CONCLUSIONS Atropine significantly reduced the prevalence of new arrhythmias during intubation particularly for children over 1 month of age, did not convert sinus tachycardia to ventricular tachycardia or fibrillation, and may contribute to the safety of intubation.
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Premedication for neonatal endotracheal intubation: results from the epidemiology of procedural pain in neonates study. Pediatr Crit Care Med 2013; 14:e169-75. [PMID: 23439457 DOI: 10.1097/pcc.0b013e3182720616] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe the frequency and nature of premedications used prior to neonatal endotracheal intubation; to confront observed practice with current recommendations; and to identify risk factors for the absence of premedication. DESIGN, SETTING, AND PATIENTS Data concerning intubations were collected prospectively at the bedside as part of an observational study collecting around-the-clock data on all painful or stressful procedures performed in neonates during the first 14 days of their admission to 13 tertiary care units in the region of Paris, France, between 2005 and 2006. INTERVENTION Observational study. MEASUREMENTS AND MAIN RESULTS Specific premedication prior to endotracheal intubation was assessed. Ninety one intubations carried out on the same number of patients were analyzed. The specific premedication rate was 56% and included mostly opioids (67%) and midazolam (53%). Compared with recent guidance from the American Academy of Pediatrics, used premedications could be classified as "preferred" (12%), "acceptable" (18%), "not recommended" (27%), and "not described" (43%). In univariate analysis, infants without a specific premedication compared with others were younger at the time of intubation (median age: 0.7 vs. 2.0 days), displayed significantly more frequent spontaneous breathing at the time of intubation (31% vs. 12%) and a higher percentage of analgesia for all other painful procedures (median values: 16% vs. 6%). In multivariate analysis, no factor remained statistically significant. CONCLUSIONS Premedication use prior to neonatal intubation was not systematically used and when used it was most frequently inconsistent with recent recommendations. No patient- or center-related independent risk factor for the absence of premedication was identified in this study.
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Orliaguet G. Sédation et analgésie en structure d’urgence. Pédiatrie : quelle sédation et analgésie pour l’intubation trachéale chez l’enfant ? ACTA ACUST UNITED AC 2012; 31:377-83. [DOI: 10.1016/j.annfar.2012.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Orliaguet G. [Sedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for pediatric patients? Pharmacology]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:359-368. [PMID: 22445224 DOI: 10.1016/j.annfar.2012.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- G Orliaguet
- Département d'anesthésie-réanimation, hôpital Necker-Enfants-malades, université Paris Descartes, Paris 5, 149, rue de Sèvres, 75730 Paris cedex 15, France.
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Urgent laparotomy helped resuscitate a neonate with increased intra-abdominal pressure who had cardiac arrest with anesthetic induction. J Clin Anesth 2012; 24:170-1. [PMID: 22414718 DOI: 10.1016/j.jclinane.2011.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 12/10/2010] [Accepted: 02/25/2011] [Indexed: 11/22/2022]
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Performing and teaching nonelective tracheal intubation in pediatric intensive care: finding the right balance between safety and training. Pediatr Crit Care Med 2012; 13:108-9. [PMID: 22222652 DOI: 10.1097/pcc.0b013e318202f5dc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Eich C, Weiss M, Neuhaus D, Strauss J, Jöhr M, Becke K. Incidence of complications associated with rapid sequence induction (RSI) in children - it is a matter of age and technique. Paediatr Anaesth 2010; 20:898-9; author reply 899. [PMID: 20716086 DOI: 10.1111/j.1460-9592.2010.03381.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gencorelli FJ, Fields RG, Litman RS. Complications during rapid sequence induction of general anesthesia in children: a benchmark study. Paediatr Anaesth 2010; 20:421-4. [PMID: 20337954 DOI: 10.1111/j.1460-9592.2010.03287.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Determine incidence of complications such as difficult or failed intubation, hypoxemia, hypotension, and bradycardia in children undergoing rapid sequence intubation (RSI) in a pediatric anesthesia department in a tertiary care children's hospital. AIM To establish a benchmark to be used by other institutions and nonanesthesiologists performing RSI in children. BACKGROUND RSI is being increasingly performed in the nonoperating room setting by nonanesthesiologists. No published studies exist to establish a benchmark of intubation success or failure and complications in this patient population. METHODS/MATERIALS Retrospective cohort analysis of children aged 3-12 undergoing RSI from 2001 to 2006. RESULTS One thousand seventy children underwent RSI from 2001 to 2006. Twenty (1.9%) developed moderate hypoxemia (SpO(2) 80-89%), 18 (1.7%) demonstrated severe hypoxemia (SpO(2) < 80%), 5 (0.5%) developed bradycardia (heart rate <60), and 8 (0.8%) developed hypotension (systolic blood pressure <70 mmHg). One patient had emesis of gastric contents but no evidence of pulmonary aspiration or hypoxemia. Eighteen (1.7%) children were noted to be difficult to intubate and required more than one intubation attempt. All were eventually intubated without significant complications. Patients between 10 and 19 kg had a higher incidence of severe hypoxemia when compared with older children (P < 0.001). There was no association between choice of muscle relaxant and any complication. CONCLUSIONS In our cohort of 1070 children who underwent RSI, difficult intubation was encountered in 1.7% and transient oxyhemoglobin desaturation occurred in 3.6%. Severe hypoxemia was more likely in children <20 kg. There were no children who could not be intubated, and there were no long-term or permanent complications.
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Affiliation(s)
- Frank J Gencorelli
- Department of Anesthesiology, Hospital of the University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Evaluation and Management of Moderate to Severe Pediatric Head Trauma. J Emerg Med 2009; 37:63-8. [DOI: 10.1016/j.jemermed.2009.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Revised: 01/30/2009] [Accepted: 02/05/2009] [Indexed: 11/21/2022]
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Abstract
The emergency airway management of children and adolescents with critical illnesses may necessitate rapid sequence intubation with a sedating and a neuromuscular blocking agent. Etomidate and rocuronium have become increasingly popular for the sedation and paralysis, respectively, of pediatric patients in rapid sequence intubation, and there are many advantages to the use of both agents. Both etomidate and rocuronium have a rapid onset of action, and both agents are relatively free of hemodynamic adverse effects. Etomidate does, however, suppress adrenal function, and consequently, its use in patients with septic shock is controversial. Rocuronium can produce optimal intubating conditions without the serious complications that can accompany succinylcholine. The available evidence supports the safety of etomidate and rocuronium in rapid sequence intubation but also suggests that more prospective studies are needed in pediatric patients.
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Weiss M, Gerber A. Anästhesieeinleitung und Intubation beim Kind mit vollem Magen. Anaesthesist 2007; 56:1210-6. [DOI: 10.1007/s00101-007-1281-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Absolom M, Roberts R, Bahlmann UB, Hall JE, Armstrong T, Turley A. The use of impedance respirometry to confirm tracheal intubation in children. Anaesthesia 2006; 61:1145-8. [PMID: 17090233 DOI: 10.1111/j.1365-2044.2006.04838.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Accidental oesophageal intubation can occur in children and is a cause of morbidity and mortality. This study investigated the use of impedance respirometry to determine tracheal tube position in children aged 1-10 years. Eighty children were recruited and, after induction of anaesthesia, two identical tracheal tubes were inserted: one into the trachea and one into the oesophagus. The breathing system was attached to one of the tubes chosen at random. A blinded observer was asked to identify the position of the tube within six breaths using impedance respirometry. The positions of 76 out of 80 tubes were correctly identified. Of those incorrectly identified, one was in the trachea and three were in the oesophagus. The sensitivity of the test was 0.975 and the specificity 0.925. The median number of breaths needed to identify the position of the tubes was 2.0 for both groups. This is not a perfect technique in the population studied but when used with other methods of tracheal tube position identification, its use could decrease the time taken to identify incorrect placement.
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Affiliation(s)
- M Absolom
- University of Wales College of Medicine, Cardiff, Wales, UK
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21
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Dempsey EM, Al Hazzani F, Faucher D, Barrington KJ. Facilitation of neonatal endotracheal intubation with mivacurium and fentanyl in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2006; 91:F279-82. [PMID: 16464937 PMCID: PMC2672731 DOI: 10.1136/adc.2005.087213] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endotracheal intubation in the neonate is painful and is associated with adverse physiological effects. Some premedication regimens have been shown to reduce these effects, but the optimal regimen is not yet determined. METHOD Data on semi-elective intubations were prospectively collected in the neonatal intensive care unit over a six month period. Patients received 20 microg/kg atropine, 200 microg/kg mivacurium (a non-depolarising muscle relaxant) followed by 5 microg/kg fentanyl. RESULTS Thirty three patients were electively intubated during this time period. The primary reason for intubation was surfactant administration (53%). Median (range) birth weight, gestational age, and age at intubation were 1360 g (675-4200), 29 weeks (25-38), and 33 hours (1-624) respectively. Twenty two of the infants were intubated on the first attempt. Median duration from initial insertion of the laryngoscope to successful intubation was 60 seconds (15 seconds to 20 minutes). In 18 cases, the first attempt was by a trainee with no previous successful intubation experience, 10 of whom intubated within two attempts. Muscle relaxation occurred at a mean (SD) of 94 (51) seconds, and mean (range) time to return of spontaneous movements was 937 seconds (480-1800). Intubation conditions were scored as excellent using a validated intubation scale. CONCLUSION Effective analgesia can be administered and intubation performed with some brief desaturations, even when junior personnel are being taught their first intubation. In this first report of mivacurium for intubation in the newborn, effective bag and mask ventilation was easily achieved during muscle relaxation and was associated with excellent intubation conditions, permitting a high success rate for inexperienced personnel.
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Affiliation(s)
- E M Dempsey
- Department of Pediatrics, Mcgill University Health Center, Montreal, Canada.
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22
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Abstract
Pseudocholinesterase deficiency is usually identified when an anesthetized patient has prolonged paralysis after receiving neuromuscular blocking agents dependent on pseudocholinesterase enzymes for hydrolysis. This rare complication, most frequently associated with succinylcholine, can occur with the use of mivacurium, one of the newer nondepolarizing muscle relaxants also hydrolyzed by pseudocholinesterase. Prolonged paralysis has occurred 3 times in the past 2 years at this pediatric hospital after administration of mivacurium. The following case study describes causality and interventions for a patient with prolonged paralysis after receiving mivacurium.
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Affiliation(s)
- Kathy Kendrick
- PACU and Day Surgery, Children's Healthcare of Atlanta at Egleston, 1405 Clifton Road NE, Atlanta, GA 30322, USA.
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Fastle RK, Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care 2004; 20:651-5. [PMID: 15454737 DOI: 10.1097/01.pec.0000142947.35394.81] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The American College of Emergency Physicians (ACEP) recommends atropine as adjunctive therapy to prevent reflex bradycardia prior to laryngoscopy/tracheal intubation (L/TI) in pediatric patients. OBJECTIVE To describe the incidence of reflex bradycardia and its relationship to the administration of atropine during L/TI in a Pediatric Emergency Department. DESIGN/METHODS A retrospective cohort study was designed through review of records of all patients who received L/TI in the ED at an urban children's hospital from January 1997 to March 2001. Patients meeting inclusion criteria were placed into cohorts defined by whether they had received atropine prior to L/TI or not. RESULTS One hundred sixty-three patients received L/TI during the study period. One hundred forty-three patients met inclusion criteria. Sixty-eight patients received atropine (atropine group) prior to L/TI. Seventy-two percent of atropine group patients met ACEP criteria for atropine pretreatment. Seventy-five patients did not receive atropine pretreatment (no-atropine group). Forty-three percent of no-atropine group patients met ACEP criteria for pretreatment with atropine. The atropine group was younger [mean 22.5 vs. 36.4 months, P = 0.003, 95% CI (-28.5, 0.70)], averaged the same number of intubation attempts [1.6 vs. 1.5, P = 0.941, 95% CI 0.1 (-0.3,0.4)], and had normal or elevated HR for age prior to L/TI (mean 159 bpm). Hypoxia occurred more often in the atropine group [28% vs. 16%, P = 0.046, 95% CI for difference (0.3, 27.1)]. Bradycardia was noted in 6 patients during L/TI; 3 in the atropine group and 3 in the no-atropine group. CONCLUSION Atropine is not routinely administered prior to L/TI in this pediatric ED. Pretreatment with atropine did not prevent bradycardia in all cases. These data suggest that use of atropine prior to L/TI may not be required for all pediatric patients. Some patients will experience bradycardia regardless of atropine pretreatment.
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Affiliation(s)
- Rebecca K Fastle
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado Health Sciences Center and The Children's Hospital, Denver, CO, USA.
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Abstract
OBJECTIVE The aim of this study was to investigate cases of difficult intubation in pediatric cardiac surgical patients and to evaluate the importance of associated congenital abnormalities. DESIGN Retrospective analysis. SETTING Departments of Anesthesiology and Pediatric Cardiovascular Surgery of a tertiary university hospital. PARTICIPANTS All children undergoing congenital heart surgery. INTERVENTIONS Patients who had difficult intubations according to their anesthetic charts were further evaluated from hospital files for demographic characteristics, associated congenital abnormalities, and perioperative airway and/or respiratory complications. MEASUREMENTS AND MAIN RESULTS A total of 1,278 pediatric patients with congenital heart disease were operated on from January 1999 to July 2002. Difficult intubation was encountered in 16 cases (1.25%). Two of these were newborns, 11 were infants, and 3 were in the pediatric age group. Anterior larynx was the most common reason for difficult intubation (7 cases, 43.7%). There were associated syndromes and/or other congenital abnormalities in 8 children (50%). CONCLUSION The likelihood of difficult intubation during pediatric cardiac surgery, especially in cases with other congenital pathologies should be kept in mind, and the anesthetic approach must be planned accordingly.
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Affiliation(s)
- Elif A Akpek
- Department of Anesthesiology, Bakent University, Ankara, Turkey.
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Kennedy RM, Luhmann JD, Luhmann SJ. Emergency department management of pain and anxiety related to orthopedic fracture care: a guide to analgesic techniques and procedural sedation in children. Paediatr Drugs 2004; 6:11-31. [PMID: 14969567 DOI: 10.2165/00148581-200406010-00002] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Orthopedic fractures and joint dislocations are among the most painful pediatric emergencies. Safe and effective management of fracture-related pain and anxiety in the emergency department reduces patient distress during initial evaluation and often allows definitive management of the fracture. No consensus exists on which pharmacologic regimens for procedural sedation/analgesia are safest and most effective. For some children, control of fracture pain is the primary goal, whereas for others, relief from anxiety is an additionally important objective. Furthermore, strategies for the management of fracture pain may vary by fracture location and patient characteristics; thus, no single regimen is likely to provide the best means of analgesia and anxiolysis for all patients. Effective analgesia can be provided by local or regional anesthesia, such as hematoma, Bier, or nerve blocks. Alternatively, induction of deep sedation with analgesic agents such as ketamine or fentanyl, often combined with sedative-anxiolytic agents such as midazolam, may be used to manage distress associated with fracture reduction. A combination of local anesthesia with moderate sedation, for example nitrous oxide, is another attractive option.
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Affiliation(s)
- Robert M Kennedy
- Department of Pediatrics, Division of Emergency Medicine, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri 63110-1077, USA.
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Marvez E, Weiss SJ, Houry DE, Ernst AA. Predicting adverse outcomes in a diagnosis-based protocol system for rapid sequence intubation. Am J Emerg Med 2003; 21:23-9. [PMID: 12563574 DOI: 10.1053/ajem.2003.50002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Eduardo Marvez
- Louisiana State University/Charity Hospital, New Orleans, LA, USA
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Flick RP, Schears GJ, Warner MA. Aspiration in pediatric anesthesia: is there a higher incidence compared with adults? Curr Opin Anaesthesiol 2002; 15:323-7. [PMID: 17019220 DOI: 10.1097/00001503-200206000-00008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Recent data in both adults and children have suggested that the incidence and severity of the pulmonary aspiration of gastric contents has declined. Previous studies have indicated that aspiration is more common in children than in adults. This review will examine the available data to compare the incidence and severity of aspiration in adults and children. RECENT FINDINGS There are several studies, some of which have been published recently, that have provided an epidemiologic perspective on the problem of aspiration. SUMMARY Based on the available data, aspiration appears to be slightly more common in children than in adults. The difference, however, is less than that previously reported. Morbidity associated with aspiration is rare in all age groups. This is especially true for children.
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Affiliation(s)
- Randall P Flick
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Nieman CT, Merlino JI, Kovach B, Polk JD, Mancuso C, Fallon WF. Intubated pediatric patients requiring transport: a review of patients, indications, and standards. Air Med J 2002; 21:22-5. [PMID: 11805763 DOI: 10.1067/mmj.2002.121715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION We could not find any studies of nontertiary care facilities performing intubation for patients requiring transport to definitive pediatric care. The purpose of our study was to determine the current practices of pediatric airway management in the prehospital and transport environments. METHODS A retrospective analysis of all patients younger than 16 years transported by our flight program during a 2-year period served as the population of interest. The flight records (RN and MD documentation) for intubated patients were analyzed for medications, methods, outcomes, and other descriptive endpoints. As a matter of program policy, all pediatric transports are subjected to peer review in the performance improvement committee. RESULTS During the review period, 732 patients younger than 16 years (range: 30 days to 15 years) were transported by our flight program. Of the 148 (20%) patients intubated for airway control, 81 were boys (55%), and 67 were girls (45%). Sixteen percent were younger than 1 year, 24% were 1 to 2 years old, 18% were 3 to 5, 20% were 6 to 11, and 22% were 12 to 15. Indicators for intubation included unresponsiveness or arrest, 42 (28%); seizures, 38 (26%); respiratory failure, 28 (19%); decreased level of consciousness (LOC), 14 (9%); airway protection, 13 (9%); combativeness, 11 (7%); and other, 2 (1%). Children were intubated most frequently by the referring physician (92 children, 62% of patients). The flight crew performed 49 (33%) intubations, and EMS staff performed seven (5%). Three children were nasally intubated. Significant variation occurred in medications used, endotracheal tube size and position, and nasogastric decompression. No single group performed better or worse than the others in our review. CONCLUSION Variability exists in the application of pediatric airway management techniques, including pharmacologic modes and intubation indications.
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Affiliation(s)
- Carolyn T Nieman
- Division of Trauma, Critical Care, Burns, and Metro Life Flight, Department of Surgery, Case Western Reserve University, Cleveland, Ohio 44109, USA
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Gerardi M, Givens TG, del Rey JG, Wiebe RA. Ask the experts: Pain and sedation case scenarios. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2000. [DOI: 10.1016/s1522-8401(00)90004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Almeida JF, Kalil Filho WJ, Troster EJ. Neuromuscular blockade in children. REVISTA DO HOSPITAL DAS CLINICAS 2000; 55:105-10. [PMID: 10983014 DOI: 10.1590/s0041-87812000000300007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Neuromuscular blocking agents (NMBAs) have been widely used to control patients who need to be immobilized for some kind of medical intervention, such as an invasive procedure or synchronism with mechanical ventilation. The purpose of this monograph is to review the pharmacology of the NMBAs, to compare the main differences between the neuromuscular junction in neonates, infants, toddlers and adults, and moreover to discuss their indications in critically ill pediatric patients. Continuous improvement of knowledge about NMBAs pharmacology, adverse effects, and the many other remaining unanswered questions about neuromuscular junction and neuromuscular blockade in children is essential for the correct use of these drugs. Therefore, the indication of these agents in pediatrics is determined with extreme judiciousness. Computerized (Medline 1990-2000) and active search of articles were the mechanisms used in this review.
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Affiliation(s)
- J F Almeida
- Department of Pediatrics, Hospital das Clínicas, Faculty of Medicine, University of São Paulo
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