The effect of atropine on rhythm and conduction disturbances during 322 critical care intubations

Airway Management of Critically Ill Pediatric Patients with Suspected or Proven Coronavirus Disease 2019 Infection: An Intensivist Point of View

Advanced airway management of critically ill children is crucial for novel coronavirus disease 2019 (COVID-19) management in the pediatric intensive care unit, whether due to shock and hemodynamic collapse or acute respiratory failure. In this article, intubation is challenging due to the particularities of children's physiology and the underlying disease's pathophysiology, especially when an airborne pathogen, like COVID-19, is present. Unfortunately, published recommendations and guidelines for COVID-19 in pediatrics do not address in-depth endotracheal intubation in acutely ill children. We discussed the caveats and pitfalls of intubation in critically ill children.

Atropine does not prevent hypoxemia and bradycardia in tracheal intubation in the pediatric emergency department: observational study

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.

Antiarrhythmic Drug Dosing in Children-Review of the Literature

Antiarrhythmic drugs represent a mainstay of pediatric arrhythmia treatment. However, official guidelines and consensus documents on this topic remain scarce. There are rather uniform recommendations for some medications (including adenosine, amiodarone, and esmolol), while there are only very broad dosage recommendations for others (such as sotalol or digoxin). To prevent potential uncertainties and even mistakes with regard to dosing, we summarized the published dosage recommendations for antiarrhythmic drugs in children. Because of the wide variations in availability, regulatory approval, and experience, we encourage centers to develop their own specific protocols for pediatric antiarrhythmic drug therapy.

Rapid Sequence Intubation Experiences in the Pediatric Emergency Department

Aim: Patient selection and management of rapid sequence intubation application in the emergency department can be challenging for clinicians. In this study, we aimed to describe the demographic information, clinical characteristics and medical conditions of the patients who underwent rapid sequence intubation in the children's emergency department of our hospital and to present patient management strategies. Methods: Cases under the age of 18 who underwent rapid sequence intubation in the emergency department between January 2021 and January 2022 were retrospectively analyzed. Results: 11 patients were included in the study. The median age of the patients was 6 years (min-max 2-15), 7 of them were girls (63,6%). The median time from symptom onset to presentation was 120 minutes (min-max 15 minutes-2 weeks). RSI indications were trauma (n=5), mass (n=4), ventriculoperitoneal shunt dysfunction (n=1), refractory status epilepticus (n=1). All patients had focal neurological deficits on examination. The median value of Glasgow coma scale scores of the patients was 8 (min-max 4-15). The first neuroimaging method was cranial tomography in ten (90.9%) patients. Intracranial hemorrhage was present in 45.4% (5 patients) of the patients. No complications were observed in any of the patients during rapid sequence intubation application. One patient each died due to intracranial hemorrhage and shunt dysfunction. Neurological deficits (dysarthria, gait disturbance, hemiparesis, visual impairment) were detected in five patients during their first month follow-up. Conclusion: This retrospective study identified critically ill children who were admitted to the emergency department with acute neurological symptoms and underwent RSI to prevent increased intracranial pressure and further brain damage.

Incidence of Bradycardia and the Use of Atropine in Pediatric Rapid Sequence Intubation in the Emergency Department

OBJECTIVE

Bradycardia during rapid sequence intubation (RSI) is an uncommon but serious adverse effect encountered in pediatric intubations. Atropine has historically been used in the pediatric population as RSI premedication to prevent bradycardia, especially when using succinylcholine as an induction agent. The objective of this analysis was to identify the incidence of bradycardia with or without atropine use.

METHODS

This single-center, retrospective, observational case series reviewed pediatric patients up to 18 years old requiring intubation from January 1, 2015, to December 31, 2018. Bradycardia was determined by analyzing heart rates associated with time during and up to 5 minutes after intubation.

RESULTS

A total of 62 patients were included. Three (4.8%) patients experienced a bradycardic event during intubation. A total of 15 (24.2%) patients received atropine for pretreatment of RSI. Incidence of bradycardia was similar between those who received atropine and those who did not. An increasing trend in atropine use was shown throughout the assessment period, yet only 18 (29%) patients met criteria for atropine pretreatment based on the 2015 Pediatric Advanced Life Support guideline recommendations for RSI.

CONCLUSION

Bradycardia incidence was low in pediatric patients undergoing RSI in our emergency department. Use of atropine or succinylcholine did not affect the incidence of bradycardia during pediatric intubation over this study period. Our results show a low incidence of bradycardia and support the 2015 Pediatric Advanced Life Support Guideline recommendation of limiting the use of atropine premedication in pediatric intubations.

Management of Pediatric Septic Shock and Acute Respiratory Distress Syndrome in Thailand: A Survey of Pediatricians

Introduction: Pediatric septic shock and acute respiratory distress syndrome (pARDS) are major causes of morbidity and mortality in pediatric intensive care units (PICUs). While standardized guidelines for sepsis and pARDS are published regularly, their implementation and adherence to guidelines are different in resource-rich and resource-limited countries. The purpose of this study was to conduct a survey to ascertain variation in current clinician-reported practice in pediatric septic shock and acute respiratory distress syndrome, and the clinician skills in a variety of hospital settings throughout Thailand. Methods: We conducted an electronic survey in pediatricians throughout the country between August 2020 and February 2021 using multiple choice questions and clinical case scenarios based on the 2017 American College of Critical Care Medicine's Consensus guideline for pediatric and neonatal septic shock and the 2015 Pediatric Acute Lung Injury Consensus Conference. Results: The survey elicited responses from 255 pediatricians (125 general pediatricians, 38 pulmonologists, 27 cardiologists, 32 intensivists, and 33 other subspecialists), with 54.5% of the respondents having <5 years of PICU experience. Among the six sepsis scenarios, 72.5 and 78.4% of the respondents had good adherence to the guidelines for managing fluid refractory shock and sedation for intubation, respectively. The ICU physicians reported greater adherence during more complex shock. In ARDS scenarios, 80.8% of the respondents reported having difficulty diagnosing ARDS mimic conditions and used lesser PEEP than the recommendation. Acceptance of permissive hypercapnia and mild hypoxemia was accepted by 62.4 and 49.4% of respondents, respectively. The ICU physicians preferred decremental PEEP titration, whereas general pediatricians preferred incremental PEEP titration. Conclusion: This survey variation could be the result of resource constraints, knowledge gaps, or ambiguous guidelines. Understanding the perspective and rationale for variation in pediatricians' practices is critical for successful guideline implementation.

Pediatric Life Support Update: 2015 American Heart Association Highlights

Despite improving survival rates for pediatric cardiac arrest victims, they remain strikingly low. Evidence for pediatric cardiopulmonary resuscitation is limited with many areas of ongoing controversy. The American Heart Association provides updated guidelines for life support based on comprehensive reviews of evidence-based recommendations and expert opinions. This facilitates the translation of scientific discoveries into daily patient care, and familiarization with these guidelines by health care providers and educators will facilitate the widespread, consistent, and effective care for patients.

Singapore Paediatric Resuscitation Guidelines 2016

We present the revised 2016 Singapore paediatric resuscitation guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, as well as the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council released in October 2015, were debated and discussed by the workgroup. The final recommendations for the Singapore Paediatric Resuscitation Guidelines 2016 were derived after carefully reviewing the current available evidence in the literature and balancing it with local clinical practice.

American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock

OBJECTIVES

The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock."

DESIGN

Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups.

MEASUREMENTS AND MAIN RESULTS

The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations.

CONCLUSIONS

The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.

Medical Emergencies in Pediatric Dentistry

Medical emergencies that are life threatening can occur in dental practice. Complications may arise because of an underlying disease or a reaction to medication. Reactions to medications may be allergic and toxic. The most common reactions are toxic reactions to local anesthetics, whereas allergies occur mainly as a consequence of the application of antibiotics, usually penicillin. In response to stress, vasovagal syncope typically occurs. Other causes may be related to an underlying disease-specific pathology (such as acute asthma attack, diabetic ketoacidosis, hypoglycemia, or seizures) or accidents (aspiration of a foreign body causing obstruction of the respiratory system). For all the above conditions, guidelines have been established that need to be known. If complications occur or necessary measures are not taken, it can lead to cardiac and respiratory arrest. Therefore, cardiopulmonary resuscitation is needed. All procedures and dosages should be adapted to the age of the child.

The therapeutic value of atropine for critical care intubation

Recent studies of atropine during critical care intubation (CCI) have revealed that neonates frequently experience bradycardia, are infrequently affected by ventricular arrhythmias and conduction disturbances and deaths have not been reported in a series of studies. The indiscriminate use of atropine is unlikely to alter the outcome during neonatal CCI other than reducing the frequency of sinus tachycardia. In contrast, older children experience a similar frequency of bradycardia to neonates and are more frequently affected by ventricular arrhythmias and conduction disturbances. Mortality during CCI is in the order of 0.5%. Atropine has a beneficial effect on arrhythmias and conduction disturbances and may reduce paediatric intensive care unit mortality. The use of atropine for children >1 month of age may positively influence outcomes beyond a reduction in the frequency of sinus bradycardia. There is indirect evidence that atropine should be used for intubation during sepsis. Atropine should be considered when using suxamethonium. The reliance on heart rate as the sole measure of haemodynamic function during CCI is no longer justifiable. Randomised trials of atropine for mortality during CCI in general intensive care unit populations are unlikely to happen. As such, future research should be focused on establishing of a gold standard for haemodynamic decompensation for CCI. Cardiac output or blood pressure are the most likely candidates. The 'lost beat score' requires development but has the potential to be developed to provide an estimation of risk of haemodynamic decompensation from ECG data in real time during CCI.

Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study

OBJECTIVES

Tracheal intubation in PICUs is often associated with adverse tracheal intubation-associated events. There is a paucity of data regarding medication selection for safe tracheal intubations in PICUs. Our primary objective was to evaluate the association of medication selection on specific tracheal intubation-associated events across PICUs.

DESIGN

Prospective observational cohort study.

SETTING

Nineteen PICUs in North America.

SUBJECTS

Critically ill children requiring tracheal intubation.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Using the National Emergency Airway Registry for Children, tracheal intubation quality improvement data were prospectively collected from July 2010 to March 2013. Patient, provider, and practice characteristics including medications and dosages were collected. Adverse tracheal intubation-associated events were defined a priori. A total of 3,366 primary tracheal intubations were reported. Adverse tracheal intubation-associated events occurred in 593 tracheal intubations (18%). Fentanyl and midazolam were the most commonly used induction medications (64% and 58%, respectively). Neuromuscular blockade was used in 92% of tracheal intubation with the majority using rocuronium (64%) followed by vecuronium (20%). Etomidate and succinylcholine were rarely used (1.6% and 0.7%, respectively). Vagolytics were administered in 37% of tracheal intubations (51% in infants; 28% in > 1 yr old; p < 0.001). Ketamine was used in 27% of tracheal intubations but more often for tracheal intubations in patients with unstable hemodynamics (39% vs 25%; p < 0.001). However, ketamine use was not associated with lower prevalence of new hypotension (ketamine 8% vs no ketamine 14%; p = 0.08).

CONCLUSIONS

In this large, pediatric multicenter registry, fentanyl, midazolam, and ketamine were the most commonly used induction agents, and the majority of tracheal intubations involved neuromuscular blockade. Ketamine use was not associated with lower prevalence of hypotension.

Site-level variance for adverse tracheal intubation-associated events across 15 North American PICUs: a report from the national emergency airway registry for children*

OBJECTIVE

Tracheal intubation in PICUs is associated with adverse tracheal intubation-associated events. Patient, provider, and practice factors have been associated with tracheal intubation-associated events; however, site-level variance and the association of site-level characteristics on tracheal intubation-associated event outcomes are unknown. We hypothesize that site-level variance exists in the prevalence of tracheal intubation-associated events and that site characteristics may affect outcomes.

DESIGN

Prospective observational cohort study.

SETTING

Fifteen PICUs in North America.

SUBJECTS

Critically ill pediatric patients requiring tracheal intubation.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Tracheal intubation quality improvement data were collected in 15 PICUs from July 2010 to December 2011 using a National Emergency Airway Registry for Children with robust site-specific compliance. Tracheal intubation-associated events and severe tracheal intubation-associated events were explicitly defined a priori. We analyzed the association of site-level variance with tracheal intubation-associated events using univariate analysis and adjusted for previously identified patient- and provider-level risk factors. Analysis of 1,720 consecutive intubations revealed an overall prevalence of 20% tracheal intubation-associated events and 6.5% severe tracheal intubation-associated events, with considerable site variability ranging from 0% to 44% tracheal intubation-associated events and from 0% to 20% severe tracheal intubation-associated events. Larger PICU size (> 26 beds) was associated with fewer tracheal intubation-associated events (18% vs 23%, p = 0.006), but the presence of a fellowship program was not (20% vs 18%, p = 0.58). After adjusting for patient and provider characteristics, both PICU size and fellowship presence were not associated with tracheal intubation-associated events (p = 0.44 and p = 0.18, respectively). Presence of mixed ICU with cardiac surgery was independently associated with a higher prevalence of tracheal intubation-associated events (25% vs 15%; p < 0.001; adjusted odds ratio, 1.81; 95% CI, 1.29-2.53; p = 0.01). Substantial site-level variance was observed in medication use, which was not explained by patient characteristic differences.

CONCLUSIONS

Substantial site-level variance exists in tracheal intubation practice, tracheal intubation-associated events, and severe tracheal intubation-associated events. Neither PICU size nor fellowship training program explained site-level variance. Interventions to reduce tracheal intubation-associated event prevalence and severity will likely need to be contextualized to variability in individual ICUs patients, providers, and practice.

Estimating 'lost heart beats' rather than reductions in heart rate during the intubation of critically-ill children

Purpose

Reductions in heart rate occur frequently in children during critical care intubation and are currently considered the gold standard for haemodynamic instability. Our objective was to estimate loss of heart beats during intubation and compare this to reduction in heart rate alone whilst testing the impact of atropine pre-medication.

Methods

Data were extracted from a prospective 2-year cohort study of intubation ECGs from critically ill children in PICU/Paediatric Transport. A three step algorithm was established to exclude variation in pre-intubation heart rate (using a 95%CI limit derived from pre-intubation heart rate variation of the children included), measure the heart rate over time and finally the estimate the numbers of lost beats.

Results

333 intubations in children were eligible for inclusion of which 245 were available for analysis (74%). Intubations where the fall in heart rate was less than 50 bpm were accompanied almost exclusively by less than 25 lost beats (n = 175, median 0 [0–1]). When there was a reduction of >50 bpm there was a poor correlation with numbers of lost beats (n = 70, median 42 [15–83]). During intubation the median number of lost beats was 8 [1]–[32] when atropine was not used compared to 0 [0–0] when atropine was used (p<0.001).

Conclusions

A reduction in heart rate during intubation of <50 bpm reliably predicted a minimal loss of beats. When the reduction in heart rate was >50 bpm the heart rate was poorly predictive of lost beats. A study looking at the relationship between lost beats and cardiac output needs to be performed. Atropine reduces both fall in heart rate and loss of beats. Similar area-under-the-curve methodology may be useful for estimating risk when biological parameters deviate outside normal range.