A national survey of atropine use by Australian anaesthetists

Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation

Succinylcholine is often used to facilitate neonatal and pediatric rapid sequence intubation in the emergency department, and most relevant literature recommends administering atropine prior to succinylcholine to reduce the risk of bradycardia. Given the potential complications associated with combining these medications, we searched the published literature for evidence supporting this practice. Most studies recommending atropine premedication were undertaken in the operating room setting and pertained to repeated succinylcholine dosing. Furthermore, there is little published evidence to indicate that succinylcholine-related bradycardia is a clinically important side effect. Several authors have called for the practice to cease, but, to date, these calls have gone unheeded. We found no evidence supporting atropine's use in pediatric patients prior to single-dose succinylcholine. Atropine premedication for emergency department rapid sequence intubation is unnecessary and should not be viewed as a “standard of care.”

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

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.

Atropine for critical care intubation in a cohort of 264 children and reduced mortality unrelated to effects on bradycardia

Background

Atropine has is currently recommended to facilitate haemodynamic stability during critical care intubation. Our objective was to determine whether atropine use at induction influences ICU mortality.

Methodology/Principal Findings

A 2-year prospective, observational study of all first non-planned intubations, September 2007–9 in PICU and Intensive Care Transport team of Hôpital Robert Debré, Paris, 4 other PICUs and 5 NICUs in the Paris Region, France. Follow-up was from intubation to ICU discharge. A propensity score was used to adjust for patient specific characteristics influencing atropine prescription. 264/333 (79%) intubations were included. The unadjusted ICU mortality was 7.2% (9/124) for those who received atropine compared to 15.7% (22/140) for those who did not (OR 0.42, 95%CI 0.19–0.95, p = 0.04). One child died during intubation (1/264, 0.4%). Two age sub-groups of neonates (≤28 days) and older children (>28 days, <8 years) were examined. This difference in mortality arose from the higher mortality in children aged over one month when atropine was not used (propensity score adjusted OR 0.22, 95%CI 0.06–0.85, p = 0.028). No effect was seen in neonates (propensity score adjusted OR 1.3, 95%CI 0.31–5.1 p = 0.74). Using the propensity score, atropine maintained the mean heart rate 45.9 bpm above that observed when no atropine was used in neonates (95%CI 34.3–57.5, p<0.001) and 43.5 bpm for older children (95%CI 25.5–61.5 bpm, p<0.001).

Conclusions/Significance

Atropine use during induction was associated with a reduction in ICU mortality in children over one month. This effect is independent of atropine’s capacity to attenuate bradycardia during intubation which occurred similarly in neonates and older children. This result needs to be confirmed in a study using randomised methodology.

Landiolol attenuates acute hemodynamic responses but does not reduce seizure duration during maintenance electroconvulsive therapy

Maintenance electroconvulsive therapy (mECT) is an outpatient procedure that requires further consideration in terms of management of ambulatory anesthesia. Although many adjunctive drugs for stabilizing hemodynamic changes during ECT have been reported, side-effects of these drugs may delay recovery and discharge from hospital. The effects of landiolol, a novel ultra-short-acting beta-adrenergic blocker, have been measured on seizure duration, hemodynamic changes, recovery from anesthesia, and cognitive function during mECT under propofol anesthesia. A total of 10 patients with depression in the remission phase, were studied in a randomized, double-blind, placebo-controlled, crossover manner. Administration of 0.1 mg/kg of landiolol immediately before anesthesia significantly blunted the increase in heart rate and blood pressure during convulsions compared with placebo; landiolol was not associated with excessive hypotension or bradycardia. Landiolol did not affect seizure duration, recovery from anesthesia, or cognitive function before or after ECT. These results suggest that landiolol can be used effectively and safely during mECT.

Rigid bronchoscopy for foreign body removal: anaesthesia and ventilation

Foreign body aspiration is a leading cause of death in children 1-3 years old, although mortality is low for children who reach the hospital. Presenting symptoms of an inhaled foreign body depends on time since aspiration. Immediately after inhalation the child starts to cough, wheeze, or have laboured breathing. If the early signs are missed, the child usually presents with fever and other signs and symptoms of chest infection. A plain chest X-ray has relatively low sensitivity and specificity for inhaled foreign body. The gold standard for diagnosis and management of this condition is rigid open tube bronchoscopy under general anaesthesia. For late presentations, time should be taken to fast the child and complete a thorough evaluation before bronchoscopy. The procedure should be performed in a well-equipped room with at least two anaesthesiologists, one with paediatric experience, in attendance. Most experienced anaesthesiologists prefer inhalational rather than intravenous induction of anaesthesia and a ventilating bronchoscope rather than intubation. Equally good results have been reported with spontaneous ventilation or positive pressure ventilation; jet ventilation is not advocated for foreign body removal in children.

Simulated epidural test doses using adrenaline and adrenaline/clonidine in sevoflurane-anaesthetized children

A pilot study was conducted using a simulated epidural test dose to ascertain the effects adrenaline, adrenaline/clonidine mixture, and clonidine alone on the accepted criteria for determining the occurrence of an epidural intravascular injection. Seventy-five ASA 1 or 2 children aged from six months to twelve years were sequentially allocated to one of three groups: group A: adrenaline 0.5 microgram/kg, group AC: adrenaline 0.5 microgram/kg and clonidine 0.3 microgram/kg, and group C: clonidine 0.3 microgram/kg. Effects on heart rate, T-wave amplitude and systolic blood pressure were determined after induction of anaesthesia and stabilization using sevoflurane in nitrous oxide and oxygen. Heart rate varied from baseline in a biphasic manner. The maximal increase in mean heart rate for all groups was < 10 beats per minute (bpm). A heart rate rise of > 10 bpm was not seen at any time in 54% of groups A and AC and 92% of group C (Chi-square 11.4, P = 0.003). T-wave changes were also biphasic. 50% of groups A and AC had no increase in T-wave size of > 25% at any sample point, compared with 96% in group C (Chi square = 49.4, P < 0.0001). 34% of groups A and AC did not have a change in systolic blood pressure of > 15 mmHg during the study compared with 100% of group C (Chi-square = 30.2, P < 0.0001). There were no significant differences between groups A and AC for any parameter. Negative predictive value estimates for the current criteria for intravascular injection were low. Clonidine 0.3 microgram/kg produced no effects on the study variables.

A prospective study of atropine premedication in flexible bronchoscopy

AIM

This study aimed to assess the effect of atropine premedication prior to flexible bronchoscopy. The rationale for using atropine is that it will dry secretions and allow a better view of the bronchial tree. There is also the theoretical benefit of protection against vasovagal episodes and bronchospasm.

METHODS

Twenty patients were randomised in a double-blind manner to receive either 500 mcg of atropine intramuscularly or 1 mL of 0.9% saline intramuscularly 30 minutes prior to bronchoscopy. Both groups received a standard dose of intramuscular pethidine. Variables studied included a pre-procedure electrocardiograph, a rhythm strip during the procedure, serial measurements of blood pressure, continuous pulse oximetry, and spirometry pre- and post-bronchoscopy. Subjective measures recorded were a secretion score, rated 0-3 by the bronchoscopist using a four point visual analogue scale. A patient questionnaire was designed to establish the presence or absence of symptoms, including those related to atropine.

RESULTS

There were no significant differences recorded in the duration of procedure, percentage fall in FEV1, secretion scores, or other physiological measures. The only significant difference between the two groups was dry mouth in the atropine group (p<0.001). There was a fall in forced vital capacity from baseline which was significant in the saline group (p<0.005), and not the atropine group, but it was not significant when compared between groups. A beta2 adrenergic agonist would, however, be more appropriate to prevent such a fall in spirometry.

CONCLUSIONS

These results fail to demonstrate a benefit of intramuscular atropine as premedication for fibreoptic bronchoscopy.

Remifentanil and propofol for sedation in children and young adolescents undergoing diagnostic flexible bronchoscopy

Flexible fibreoptic bronchoscopy (FOB) has become a useful diagnostic and therapeutic procedure in children. We investigated 26 patients (3-14 years) for FOB using a new sedation strategy. All patients received oral premedication and inhalation of topical anaesthetic. Sedation for bronchoscopy was achieved with a continuous infusion of remifentanil and intermittent boluses of propofol. Propofol injection was repeated if sedation was inadequate. Sedation could be successfully performed in all children without adverse effects. Endtidal CO2 concentration and arterial oxygen saturation remained stable throughout the study. All children were awake 5+/-1.3 min after stopping remifentanil infusion. Sedation with remifentanil/propofol is a new sedation strategy for diagnostic flexible paediatric bronchoscopy in children with spontaneous ventilation.

Rapid sequence intubation of the pediatric patient. Fundamentals of practice

Rapid-sequence intubation and rapid sequence induction of general anesthesia are synonyms and refer to the technique of choice for tracheal intubation in many pediatric patients in the emergency department. The principles of safe practice and basic standards of care uniformly apply to all clinical situations in which the technique is performed. RSI has two basic technical components: induction of general anesthesia and direct laryngoscopy with tracheal intubation. The technique is a prescribed protocol that can be modified slightly by the clinical circumstances. RSI is designed to rapidly create ideal intubating conditions, attenuate pathophysiologic reflex responses to direct laryngoscopy and tracheal intubation, and reduce the risk for pulmonary aspiration. Optimal performance requires appropriate training and knowledge, technical skill, and sound medical judgment. Medical and airway evaluation, careful patient selection, recognition of the need for consultation or safer alternatives, thorough familiarity with appropriate drug management, and attention to detail are essential for minimizing the risk for adverse complications. RSI with a rapid injection of preselected dosages of an anesthetic induction agent and muscle relaxant is the pharmacologic technique of choice. Premedication should not be routinely used. Anticipation, recognition, and management of complications are inherent to the competent delivery of all medical care. The unanticipated difficult airway is arguably the most severe complication of RSI, and all individuals performing the technique must prepare in advance a specific plan for this scenario. As with all such skills or procedures, a quality assurance program is important to monitor care, and individuals practicing RSI need to take appropriate steps to maintain competence.

Should the routine use of atropine before succinylcholine in children be reconsidered?

It is common practice to administer atropine before a first dose of succinylcholine in infants and children. However, the administration of succinylcholine without atropine has not been investigated in children. This study was designed to compare cardiovascular changes after the administration of either atropine with succinylcholine or succinylcholine alone. In 41 ASA I or II patients aged from 1 to 12 yr anaesthesia was induced with thiopentone 5 mg.kg-1. Patients were randomly allocated to receive either atropine 20 micrograms.kg-1 and succinylcholine 1.5 mg.kg-1 (n = 20) or succinylcholine 1.5 mg.kg-1 alone (n = 21). Heart rate and rhythm were recorded continuously from two minutes before induction until two minutes after tracheal intubation. Blood pressure was measured non-invasively before and after induction of anaesthesia and both immediately and two minutes after laryngoscopy. One self-limiting episode of bradycardia was recorded during laryngoscopy in a child who received atropine. Heart rate increased in both groups compared with baseline values (108 +/- 25), with a greater increase in patients who had received atropine (150 +/- 13) than in those who had not (128 +/- 18) (P < 0.05). There was no difference in mean arterial pressure or incidence of arrythmias between the two groups. No recorded arrythmias were judged to be clinically important by a cardiologist. The incidence of bradycardia after succinylcholine in the absence of atropine in children aged from 1 to 12 yr appears to be lower than previously estimated. The use of atropine before a single dose of succinylcholine in children deserves to be reconsidered.