Rapid sequence intubation (RSI) outside of the operating room in children: Medications for sedation and paralysis
- Dewesh Agrawal, MD
Dewesh Agrawal, MD
- Associate Professor of Pediatrics and Emergency Medicine
- Children's National Medical Center
- Section Editor
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Pediatric Emergency Medicine
- Texas Children’s Hospital
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic will discuss medications commonly used for sedation and paralysis outside of the operating room during RSI in children. The approach to RSI outside of the operating room in children, including the steps involved in performing RSI and the selection of sedative and paralytic agents according to patient characteristics, is discussed separately. (See "Rapid sequence intubation (RSI) outside the operating room in children: Approach".)
RAPID SEQUENCE INTUBATION
RSI describes a sequential process of preparation, sedation, and paralysis to facilitate safe, emergency tracheal intubation. Pharmacologic sedation and paralysis are induced in rapid succession to quickly and effectively perform laryngoscopy and tracheal intubation.
The goal of RSI is to quickly and safely intubate patients using sedation and paralysis. A simple, systematic approach to preparation and execution of the procedure is necessary in order to perform RSI quickly and safely (table 1 and figure 1). This approach is discussed in detail separately. (See "Rapid sequence intubation (RSI) outside the operating room in children: Approach", section on 'Approach'.)
Sedative agents are integral to the performance of RSI. They provide amnesia, blunt sympathetic responses, and can improve intubating conditions.
Each of the major induction agents in common use in children is discussed below and provided in the rapid overview (table 1). Further information about selection of sedatives and paralytics for RSI in children according to serious underlying conditions (eg, hemodynamic instability, increased intracranial pressure, status asthmaticus, or status epilepticus) is provided separately. (See "Rapid sequence intubation (RSI) outside the operating room in children: Approach", section on 'Selection of sedative agent' and "Rapid sequence intubation (RSI) outside the operating room in children: Approach", section on 'Selection of paralytic agent'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Guldner G, Schultz J, Sexton P, et al. Etomidate for rapid-sequence intubation in young children: hemodynamic effects and adverse events. Acad Emerg Med 2003; 10:134.
- Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005; 46:328.
- Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002; 18:417.
- Sivilotti ML, Filbin MR, Murray HE, et al. Does the sedative agent facilitate emergency rapid sequence intubation? Acad Emerg Med 2003; 10:612.
- Sokolove PE, Price DD, Okada P. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care 2000; 16:18.
- Ching KY, Baum CR. Newer agents for rapid sequence intubation: etomidate and rocuronium. Pediatr Emerg Care 2009; 25:200.
- Zuckerbraun NS, Pitetti RD, Herr SM, et al. Use of etomidate as an induction agent for rapid sequence intubation in a pediatric emergency department. Acad Emerg Med 2006; 13:602.
- Oglesby AJ. Should etomidate be the induction agent of choice for rapid sequence intubation in the emergency department? Emerg Med J 2004; 21:655.
- Dewhirst E, Frazier WJ, Leder M, et al. Cardiac arrest following ketamine administration for rapid sequence intubation. J Intensive Care Med 2013; 28:375.
- Zelicof-Paul A, Smith-Lockridge A, Schnadower D, et al. Controversies in rapid sequence intubation in children. Curr Opin Pediatr 2005; 17:355.
- Page P, Morgan M, Loh L. Ketamine anaesthesia in paediatric procedures. Acta Anaesthesiol Scand 1972; 16:155.
- Wyant GM. Intramuscular ketalar (CI-581) in paediatric anaesthesia. Can Anaesth Soc J 1971; 18:72.
- Brown L, Christian-Kopp S, Sherwin TS, et al. Adjunctive atropine is unnecessary during ketamine sedation in children. Acad Emerg Med 2008; 15:314.
- Sagarin MJ, Barton ED, Sakles JC, et al. Underdosing of midazolam in emergency endotracheal intubation. Acad Emerg Med 2003; 10:329.
- Salonen M, Kanto J, Iisalo E. Induction of general anesthesia in children with midazolam--is there an induction dose? Int J Clin Pharmacol Ther Toxicol 1987; 25:613.
- Hegenbarth MA, American Academy of Pediatrics Committee on Drugs. Preparing for pediatric emergencies: drugs to consider. Pediatrics 2008; 121:433.
- Dewhirst E, Naguib A, Tobias JD. Chest wall rigidity in two infants after low-dose fentanyl administration. Pediatr Emerg Care 2012; 28:465.
- phx.corporate-ir.net/phoenix.zhtml?c=175550&p=irol-newsArticle&ID=1518610&highlight= (Accessed on August 01, 2011).
- Luten RC, Kissoon N. Approach to the pediatric airway. In: Manual of Emergency Airway Management, Walls RM, Murphy MF, Luten RC, et al (Eds), Lippincott Williams and Wilkins, Philadelphia 2004. p.212.
- McAllister JD, Gnauck KA. Rapid sequence intubation of the pediatric patient. Fundamentals of practice. Pediatr Clin North Am 1999; 46:1249.
- Gerardi MJ, Sacchetti AD, Cantor RM, et al. Rapid-sequence intubation of the pediatric patient. Pediatric Emergency Medicine Committee of the American College of Emergency Physicians. Ann Emerg Med 1996; 28:55.
- Robinson AL, Jerwood DC, Stokes MA. Routine suxamethonium in children. A regional survey of current usage. Anaesthesia 1996; 51:874.
- Sanfilippo F, Santonocito C, Veenith T, et al. The role of neuromuscular blockade in patients with traumatic brain injury: a systematic review. Neurocrit Care 2015; 22:325.
- Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J 2001; 18:373.
- Won YJ, Lim BG, Lee DK, et al. Sugammadex for reversal of rocuronium-induced neuromuscular blockade in pediatric patients: A systematic review and meta-analysis. Medicine (Baltimore) 2016; 95:e4678.
- Perry J, Lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2003; :CD002788.
- McCourt KC, Salmela L, Mirakhur RK, et al. Comparison of rocuronium and suxamethonium for use during rapid sequence induction of anaesthesia. Anaesthesia 1998; 53:867.
- Smith CE, Botero C, Holbrook C, et al. Rocuronium versus vecuronium during fentanyl induction in patients undergoing coronary artery surgery. J Cardiothorac Vasc Anesth 1999; 13:567.
- Smith CE, Kovach B, Polk JD, et al. Prehospital tracheal intubating conditions during rapid sequence intubation: rocuronium versus vecuronium. Air Med J 2002; 21:26.