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 [
[1]
]. To date there have only been 2 descriptions of the use of pediatric DSI in the literature,
both in normotensive patients [
2
,
3
]. 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.To read this article in full you will need to make a payment
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to The American Journal of Emergency MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Delayed sequence intubation: a prospective observational study.Ann Emerg Med. 2015; 65: 349-355https://doi.org/10.1016/j.annemergmed.2014.09.025
- A case of delayed sequence intubation in a pediatric patient with respiratory syncytial diagnosis.Ann Emerg Med. 2013; 62: 278-279https://doi.org/10.1016/j.annemergmed.2013.03.027
- Delayed sequence intubation for management of respiratory failure in a 6-year-old child in a paediatric emergency department.Emerg Med Australas. 2014; 26: 308-309https://doi.org/10.1111/1742-6723.12196
- Emergent endotracheal intubations in children: be careful if it's late when you intubate.Pediatr Crit Care Med. 2010; 11: 343-348https://doi.org/10.1097/PCC.0b013e3181c51426
- Factors associated with oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department: findings from multivariable analyses of video review data.Acad Emerg Med. 2015; 22: 431-440https://doi.org/10.1111/acem.12633
- Preoxygenation and prevention of desaturation during emergency airway management.Ann Emerg Med. 2012; 59 ([e1])https://doi.org/10.1016/j.annemergmed.2011.10.002
- Study of the optimal duration of preoxygenation in children.J Clin Anesth. 1995; 7: 93-96https://doi.org/10.1016/0952-8180(94)00011-R
- A prospective, randomised controlled trial comparing the efficacy of pre-oxygenation in the 20 degrees head-up vs supine position.Anaesthesia. 2005; 60: 1064-1067https://doi.org/10.1111/j.1365-2044.2005.04374.x
- Preoxygenation with 20° head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults.J Anesth. 2011; 25: 189-194https://doi.org/10.1007/s00540-011-1098-3
- Positive end-expiratory pressure during induction of general anesthesia increases duration of nonhypoxic apnea in morbidly obese patients.Anesth Analg. 2005; 100: 580-584https://doi.org/10.1213/01.ANE.0000143339.40385.1B
- The effect of positive airway pressure during pre-oxygenation and induction of anaesthesia upon duration of non-hypoxic apnoea.Anaesthesia. 2004; 59: 243-247
- Apneic oxygenation via nasal prongs at 10 L/min prevents hypoxemia during tracheal intubation for elective surgery.Eur Respir J. 2013; 42: P4923
- Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department.J Emerg Med. 2011; 40: 661-667https://doi.org/10.1016/j.jemermed.2010.02.014
- Ketamine: review of its pharmacology and its use in pediatric anesthesia.Anesth Prog. 1999; 46: 10-20
- Rapid-sequence intubation: a review of the process and considerations when choosing medications.Ann Pharmacother. 2014; 48: 62-76https://doi.org/10.1177/1060028013510488
- Cardiac arrest following ketamine administration for rapid sequence intubation.J Intensive Care Med. 2012; 28: 375-379https://doi.org/10.1177/0885066612448732
Article Info
Publication History
Published online: November 19, 2015
Accepted:
November 17,
2015
Received:
November 13,
2015
Footnotes
☆Conflicts of interest and source of funding: No conflicts of interest declared. No outside funding sources.
Identification
Copyright
© 2015 Elsevier Inc. All rights reserved.