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Delayed sequence intubation with ketamine in 2 critically ill children

  • Michael J. Miescier
    Correspondence
    Corresponding author at: Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah, PO Box 581289, Salt Lake City, UT 84158. Tel.: +1 801 587 7450; fax: +1 801 587 7455.
    Affiliations
    Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
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  • Author Footnotes
    1 Tel: +1 801 581 2730; fax: +1 801 585 0603.
    Robert J. Bryant
    Footnotes
    1 Tel: +1 801 581 2730; fax: +1 801 585 0603.
    Affiliations
    Emergency Medicine (Clinical), Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
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  • Author Footnotes
    2 Tel.: +1 801 587 7450; fax: +1 801 587 7455.
    Douglas S. Nelson
    Footnotes
    2 Tel.: +1 801 587 7450; fax: +1 801 587 7455.
    Affiliations
    Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
    Search for articles by this author
  • Author Footnotes
    1 Tel: +1 801 581 2730; fax: +1 801 585 0603.
    2 Tel.: +1 801 587 7450; fax: +1 801 587 7455.
Published:November 19, 2015DOI:https://doi.org/10.1016/j.ajem.2015.11.053
      Hypoxia is a common complication during the emergent intubation of children. Several approaches may help avoid hypoxia, including semiupright patient positioning, adequate preoxygenation, and nasal cannula apneic oxygenation. Delayed sequence intubation (DSI) is a strategy to facilitate preoxygenation when standard efforts using supplemental oxygen with nonrebreather (NRB) mask are not successful. In DSI, the sedative agent ketamine is administered to facilitate effective preoxygenation via NRB mask or continuous positive airway pressure (CPAP), followed by the delayed administration of a neuromuscular blocking agent once adequate preoxygenation has been achieved. A recent prospective, observational, multicenter study of adults demonstrated that DSI using ketamine facilitated increased oxygenation saturations during preoxygenation in adults [
      • Weingart S.D.
      • Trueger N.S.
      • Wong N.
      • Scofi J.
      • Singh N.
      • Rudolph S.S.
      Delayed sequence intubation: a prospective observational study.
      ]. To date there have only been 2 descriptions of the use of pediatric DSI in the literature, both in normotensive patients [
      • Schneider E.D.
      • Weingart S.D.
      A case of delayed sequence intubation in a pediatric patient with respiratory syncytial diagnosis.
      ,
      • Löllgen R.M.
      • Webster P.
      • Lei E.
      • Weatherall A.
      Delayed sequence intubation for management of respiratory failure in a 6-year-old child in a paediatric emergency department.
      ]. We present the successful use of ketamine for DSI in 2 critically ill hypoxic children in shock requiring emergent intubation. Delayed sequence intubation is a strategy that should be considered for children who are not able to be preoxygenated for intubation using conventional strategies.
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