1532 SECTION XIV Pediatric Critical Care Anesthesia Principles in the Pediatric Intensive Care Unit intracranial pathology with well compensated or previously con trolled pressure Arterial hypertensio[.]
1532 S E C T I O N X I V Pediatric Critical Care: Anesthesia Principles in the Pediatric Intensive Care Unit • BOX 127.5 Intubation for Increased Intracranial Pressure • • • • • • • • • Prepare equipment Monitor heart rate, blood pressure, end-tidal CO2, and oxygen saturation Provide 100% oxygen and assisted ventilation as tolerated by patient Consider possible difficult airway If no airway contraindications, administer anesthetic and neuromuscular blocking agents If no associated cardiovascular compromise or hypovolemia: • Administer adjuvant agents such as fentanyl (1–2 mg/kg IV) and/or lidocaine (1 mg/kg IV), induction agents such as etomidate (0.3 mg/kg IV) or propofol (1–2 mg/kg IV), and finally relaxants such as rocuronium (0.6–1.2 mg/kg IV) or other paralytics (avoid succinylcholine for the associated ICP spikes) If concern for associated cardiovascular compromise or hypovolemia: • Administer same sequence as above However, if using propofol, be prepared to support the blood pressure with fluids and vasopressors Ketamine (1–2 mg/kg IV) can also be considered, as newer studies have shown it can be safely used in patients with increased ICP, but historically there was concern Although not available in the US, thiopental (4–6 mg/kg IV) is also classically used in this scenario Ventilate patient until drug effect achieved (consider short-term hyperventilation (Paco2 of 30–35 mm Hg) in patients with signs of critically elevated intracranial pressure) Perform laryngoscopy and orotracheal intubation ICP, Intracranial pressure; IV, intravenous intracranial pathology with well-compensated or previously controlled pressure Arterial hypertension may precipitate further hemorrhage in the child with a vascular malformation, coagulopathy, or bleeding into a tumor ICP waves may reduce cerebral perfusion pressure to ischemic levels or cause frank herniation Given the risk of life-threatening systemic and intracranial hypertension in these patients, it is clear that laryngoscopy and intubation should be undertaken with every effort to minimize stimulation and associated struggle.107,218–220 In general, efforts should be made to ensure excellent oxygenation, ventilation, and intubation under protection of profound sedation or anesthesia, with the assistance of neuromuscular blockade (Box 127.5) Neurologists and neurosurgeons are frequently hesitant to relinquish the opportunity to examine the patient after intubation, but the risk of life-threatening intracranial hypertension justifies temporarily obscuring the neurologic examination In most cases, adequate assessment is possible before intubation, and diagnostic studies require deep sedation for a period afterward Once more, with short-acting intravenous anesthetics and reversible neuromuscular blockade, a neurologic examination can be obtained soon after a safe neuroprotective intubation The patient is provided 100% oxygen by bag and mask An anesthetic or sedative agent in combination with an NMBA is administered, and manual ventilation is initiated to lower ICP as much as possible before airway manipulation Although extreme hyperventilation may decrease CBF to ischemic levels, current guidelines support ventilation to a Paco2 of approximately 30 to 35 mm Hg for patients with intracranial hypertension.221 In the hemodynamically stable patient, relatively deep anesthesia is associated with a decline in CMRO2, CBF, and ICP, provided that oxygenation and ventilation are well maintained.218,220 This deep plane of anesthesia can be achieved via multiple medications Etomidate is widely used in patients with suspected intracranial hypertension Its ability to decrease CBF without causing apparent detrimental effect on systemic hemodynamic stability makes it a useful agent However, concerns about its effect on adrenal function, perhaps even after one dose, require that caution be used in patients with sepsis or shock Because it lacks analgesic properties, combining it with an intravenous narcotic agent should be considered Propofol may also be used as an induction agent in patients with suspected intracranial hypertension Although it quickly provides a deep plane of anesthesia with decreased CMRO2, its use also requires caution because it can decrease systemic vascular resistance and the resultant hypotension could lead to poor cerebral perfusion in an already compromised brain The classic recommendation has been to avoid ketamine in patients with elevated ICP because of its potential to further increase ICP However, newer studies suggest that ketamine may be safe in this population In fact, some studies have shown that ketamine can decrease ICP and that it is associated with an overall lower mortality rate when used as a sedative in patients with elevated ICP.222,223 Many intensivists remain hesitant, however, because of the historical teaching on this drug Adjuvant agents play a critical role in achieving ideal intubating conditions in the patient with elevated ICP The main role of these adjuvants is to blunt the sympathetic surge and associated ICP spike that may occur with intubation if a patient is not adequately sedated Opioid analgesics have been used to blunt the sympathetic surge and decrease CMRO2 Although the negative hemodynamic effects of narcotics (typically, fentanyl or remifentanil) are usually modest, the effect on CMRO2 is also limited unless administered in anesthetic doses.224 Lidocaine, 1.0 to 1.5 mg/kg, decreases CMRO2 and modestly decreases the systemic and intracranial hypertensive response and cough reflex as long as the dose used is below the seizure-producing threshold Effective serum concentrations are obtained more quickly and at lower doses when it is administered intravenously than when it is administered endotracheally Previous studies have addressed patients undergoing neurosurgical procedures who are fully premedicated and monitored or patients already intubated, ventilated, and monitored in the ICU Studies addressing intubation in the acute setting are lacking.221,225–228 More recently, studies have shown that in the acute care setting, lidocaine administered by itself or in combination with fentanyl can diminish hemodynamic changes associated with intubation No available data yet prove the effects of lidocaine on ICP in the acute care setting.229 Finally, dexmedetomidine, a sedative agent that is increasingly popular among intensivists and anesthesiologists, is now being used as an adjuvant to decrease the stress response associated with intubation and extubation in patients with intracranial hypertension.230–232 Studies showing its direct effect on ICP are still scarce; however, patients with refractory intracranial hypertension were reported to require less rescue therapy when they were placed on a dexmedetomidine drip.233 Such results are encouraging and suggest the need for additional studies in this area In nearly all patients, orotracheal intubation is preferred because it is accomplished quickly and easily with less risk of prolonged manipulation and interrupted ventilation Nasotracheal intubation is contraindicated in patients with basilar skull fractures and CSF leaks as a potential source of infection or even perforation of the cribriform plate and intracranial tube placement Cervical Spine Instability Cervical spine instability is an important consideration before intubation Flexion and extension of the head on the neck occur between the atlas (C1) and the basiocciput Rotation occurs between the atlas and axis (C2), as the thin arch of the atlas pivots CHAPTER 127 Airway Management around the odontoid process Below the axis, the cervical vertebrae articulate with each other anteriorly at the intervertebral discs and posteriorly at the facet joints Further neck flexion and extension occur at these joints Anterior and posterior ligaments complete the stable spine Spinal cord injury generally occurs as a result of bony fracture, compression, or disruption of cervical ligaments In young children, actual ligamentous disruption or bony fracture is not necessary for severe cord injury, even transection, to occur; extreme stretching, as may occur in acceleration or deceleration injury, is sufficient.234–236 Spinal cord injury without radiographic abnormalities (SCIWORA) is a well-documented phenomenon in children.237 Instability results from disruption of both the anterior and posterior columns Congenital or degenerative anatomic abnormalities, penetrating wounds, or expanding mass lesions in the spinal canal may compromise cord integrity During routine intubation, the intensivist flexes the patient’s neck and extends the head In children with known or suspected cervical spine injury or instability resulting from other causes (e.g., Down syndrome or rheumatoid arthritis), manipulating the head and neck for intubation risks extending the existing condition or injury and precipitating new problems Cervical spine radiographs and knowledge about the nature of the traumatic event help define the precise injury and predict maneuvers most likely to harm, but such information is rarely complete and may be falsely reassuring For example, in 2011, the American Academy of Pediatrics stopped recommending routine neck radiographs in patients with Down syndrome Radiographs were found to be inaccurate in children under the age of years Physical examination and history of symptoms consistent with myelopathy remain the mainstay in diagnosis and referral for cervical spine instability in these patients.238 The ideal approach to intubation in this setting is still being debated.239–242 Evidence in cadavers indicates that typical airway maneuvers can cause anterior or posterior subluxation or widening of the disc space.243 Face mask, chin lift, and jaw thrust may lead to cervical spinal manipulation equivalent to that of direct laryngoscopy.244 Axial traction increases distraction and even subluxation in some patients144; in others, traction is helpful However, information about the appropriate amount of force or the correct plane in which it should be applied is rarely sufficient to make a timely informed decision Therefore, immobilization of the head and neck in the midline without traction is recommended.245 In most instances, intubation is best accomplished in these patients via the orotracheal route using an intravenous anesthetic or a combination of sedative and analgesic agents, atropine, and a nondepolarizing NMBA An assistant should immobilize the head and neck in a neutral position with one hand over the ear on each side of the head If time, equipment, and expertise permit, fiberoptic bronchoscopy may assist larynx visualization and intubation with minimal head or neck movement.246 Likewise, studies in cadavers have shown that video laryngoscopy causes less dural sac compression, cervical extension, and cervical rotation than does direct laryngoscopy Thus, video laryngoscopy is now widely used in children.247,248 If orotracheal or nasotracheal intubation cannot be accomplished because of associated facial or airway injuries or other technical obstacles, cricothyrotomy or primary tracheotomy may be indicated However, no data support either the necessity or safety of routinely using a surgical approach before attempting orotracheal intubation It is critical to note that patients with spinal cord injuries are at risk for extreme hyperkalemia and resulting dysrhythmias or cardiac arrest after receiving succinylcholine This response occurs 1533 from approximately 48 hours to to months after injury Often, cervical injury also disrupts sympathetic nervous system outflow and results in unopposed vagal tone and severe bradycardia Upper Airway Obstruction Upper airway obstruction may result from many disorders (see Chapter 47) When symptoms are related to loss of oropharyngeal muscle tone and duration of the underlying process is presumed to be brief, changing the patient’s position, reversing the effects of a drug, or placing a nasal airway may be sufficient However, when airway structures are likely severely or progressively distorted by edema, inflammation, trauma, or another space-occupying process, securing the airway is necessary Patients should be allowed to assume whatever position is most comfortable Agitation should be avoided if possible because it can worsen obstruction Supplemental oxygen is provided at the maximum concentration possible, but practitioners should avoid heightening a young child’s anxiety with overly aggressive efforts to place a mask or attempts to place an IV line A high-flow nasal cannula may be better tolerated than other forms of noninvasive ventilation and can provide some degree of positive airway pressure One study of 30 adults with obstructed airways reported no instances of desaturation during intravenous induction and maintenance of spontaneous breathing when a high-flow nasal cannula was in place.249 Similarly, a study in children showed that oxygenation was maintained by use of a high-flow nasal cannula in spontaneously breathing surgical patients with abnormal airways.250 But, again, attempts to place the high-flow cannula should be aborted if they agitate the child and worsen respiratory symptoms In general, the patient should be kept breathing spontaneously until the airway is secured In particular, use of NMBAs is dangerous and inappropriate until after the airway is controlled Distortion of the airway may be so extreme that recognition of landmarks for intubation is impossible; loss of pharyngeal tone in such patients may remove the last barrier to complete airway occlusion If NMBAs are considered or used, suggamadex should be immediately available for reversal if necessary However, reducing a child’s anxiety with cautious sedation may decrease peak inspiratory flow rate and symptoms of obstruction and make it easier to assist breathing and establish an artificial airway Ketamine and dexmedetomidine have minimal effect on a patient’s ability to breathe spontaneously and can be used when an intravenous line is present When possible, the child is gently lowered to a supine position (or to 30 degrees) and intubated by the orotracheal route When time and available expertise permit, it may be preferable to intubate in the operating room using an inhalational anesthetic in a high oxygen concentration This procedure allows the patient to breathe spontaneously until the patient is deeply anesthetized and untroubled by airway manipulation It may be especially helpful in patients with supraglottitis or when an intravenous line is not present and attempts to place one may worsen obstruction and endanger the patient In most cases, the proper tube diameter is 0.5 to 1.0 mm less than that predicted by age because of airway inflammation and edema, and no leak will be present Extubation is usually well tolerated and successful when an airway leak has developed and/or underlying pathology has resolved or been surgically addressed Facial and Laryngotracheal Injury Children with facial injuries present airway problems nearly as varied as the injuries themselves Appropriate management depends primarily on accurate assessment of airway patency at 1534 S E C T I O N X I V Pediatric Critical Care: Anesthesia Principles in the Pediatric Intensive Care Unit presentation, the rate of bleeding (if any) into the airway, and the amount of additional swelling and distortion likely to occur later Evaluation of possible ocular and intracranial injury must proceed simultaneously Profuse bleeding, unstable facial fractures, or aspiration of blood, gastric contents, or teeth causes early respiratory distress Maxillary fractures may result in a free-floating maxilla with occlusion of the nasopharynx and pressure on the tongue Isolated mandibular fractures often cause trismus but rarely cause airway obstruction or interfere with larynx visualization Airway management begins with suctioning blood and debris from the mouth and pharynx If permitted by other injuries, the child is placed with the head down and turned to the side A spontaneously breathing patient receives oxygen by mask and may not require further intervention before surgery However, some patients may require an immediate artificial airway In a study of pediatric facial trauma, 20% of patients required emergent intubation and 1.8% required a surgical airway.251 In most traumas, RSI and intubation are indicated, as the stomach is presumed to be full If there is concern that bag-mask ventilation or intubation may prove difficult, the intensivist will need to proceed with extreme caution When possible, and if patient factors and staffing allow, the patient should be taken to the operating room for intubation, with backup airway equipment such as fiberoptic scope available Surgeons should be on standby for a surgical airway if necessary If the patient is unstable and the airway must be secured immediately, then the intensivist can proceed with an RSI and intubation for placement of an orotracheal tube The surgical team should be at the bedside prepped for immediate surgical airway Nasotracheal and nasogastric tubes are avoided until the possibility of a basilar skull fracture and CSF leak is eliminated Although awake intubation is often necessary in adult trauma, this technique is extremely difficult, if not impossible, in uncooperative pediatric patients Laryngotracheal injuries may be subtle or dramatic They should be suspected in children with a history of anterior neck trauma and often cause hoarseness, stridor, subcutaneous emphysema, pneumothorax, or pneumomediastinum Aerosolized epinephrine may temporarily decrease swelling and provide a little extra time to evaluate the airway and plan intervention Performing awake intubation with carefully titrated sedation and topical anesthesia under direct vision by laryngoscopy or fiberoptic bronchoscopy minimizes the risk of sudden, complete obstruction or creation of a false passage adjacent to the airway Awake intubation is often unrealistic in the pediatric patient In this situation, an induction with maintenance of spontaneous ventilation, preferably in the operating room, needs to be weighed against the risk of full stomach and aspiration on a case-by-case basis Open-Globe Injury Children with penetrating eye injuries may require emergency intubation for respiratory failure resulting from associated injuries or other underlying problems Management in these cases seeks to prevent increases in intraocular pressure with subsequent extrusion of the vitreous and permanent blindness Intraocular pressure can be increased by struggling, crying, coughing, straining, or eye rubbing Hypoxia and hypercarbia also can increase intraocular pressure In general, central nervous system depressants, with the possible exception of ketamine, lower intraocular pressure Intubation should be performed smoothly under full muscle relaxation if possible Associated injuries and the risk of a full stomach should be taken into consideration The child should be preoxygenated with 100% oxygen, but it is important not to apply pressure to the eye with the mask Efforts to empty the stomach are delayed until the patient is fully relaxed and intubated In hemodynamically stable patients, rapidly acting sedatives or anesthetics are administered, followed by a nondepolarizing NMBA if other airway anatomy permits Succinylcholine, a depolarizing relaxant, has been associated with increased intraocular pressure, even in the absence of fasciculations, and thus should be avoided Lidocaine supplements the effect of other agents in blunting intraocular pressure increases that may occur even during a smooth intubation Newer studies also support the use of dexmedetomidine to attenuate the stress responses associated with increased intraocular pressure at the time of induction and intubation.252,253 Heavy sedation or paralysis should be maintained following intubation until after repair Key References Field S, Kelly SM, Macklem PT The oxygen cost of breathing in patients with cardiorespiratory disease Am Rev Respir Dis 1982;126:9-13 Kovac AL Controlling the hemodynamic response to laryngoscopy and endotracheal intubation J Clin Anesth 1996;8:63-79 Litman RS, Maxwell LG Cuffed versus un-cuffed endotracheal tubes in pediatric anesthesia: the debate should finally end Anesthesiology 2013;118:500-501 Newth CJ, Rachman B, Patel N, et al The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care J Pediatr 2004;144: 333-337 Nykiel-Bailey SM, McAllister JD, Schrock CR, et al Difficult airway consultation service for children: steps to implement and preliminary results Paediatr Anaesth 2015;25:363-371 Patel R, Lenczyk M, Hannallah RS, McGill WA Age and onset of desaturation in apnoeic children Can J Anaesth 1994;41:771-774 Shi F, Xiao Y, Xiong W, et al Cuffed versus uncuffed endotracheal tubes in children: a meta-analysis J Anesth 2016;30:3-11 Sullivan KJ, Kissoon N Securing the child’s airway in the emergency department Pediatr Emerg Care 2002;18:108-121 Tobias JD Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes Paediatr Anaesth 2015;2:9-19 The full reference list for this chapter is available at ExpertConsult.com e1 References Buenting JE, Dalston RM, Drake AF Nasal cavity area in term infants determined by acoustic rhinometry Laryngoscope 1994;104: 1439-1445 Arens R, McDonough JM, Corbin AM, et al Linear dimensions of the upper airway structure during development: assessment by magnetic resonance imaging Am J Respir Crit Care Med 2002;165:117-122 Rodenstein DO, Perlmutter N, Stanescu DC Infants are not obligatory nose breathers Am Rev Respir Dis 1985;131:343-347 Bergeson PS, Shaw JC Are infants really obligatory nasal breathers? Clin Pediatr (Phila) 2001;40:567-569 Onal E, Lopata M, O’Connor TO Diaphragmatic and genioglossal electromyelogram response to CO2 rebreathing in humans J Appl Physiol 1981;50:1052-1055 Tobias JD Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes Paediatr Anaesth 2015;2:9-19 Litman RS, Weissend EE, Shibata D, et al Developmental changes of laryngeal dimensions in unparalyzed, sedated children Anesth Analg 2003;98:41-45 Dalal PG, Murray D, Messner AH, et al Pediatric laryngeal dimensions: an age-based analysis Anesth Analg 2009;108:1475-1479 Sreenan C, Lemke RP, Hudson-Mason A, et al High-flow nasal cannulae in the management of apnea of prematurity: a comparison with conventional nasal continuous positive airway pressure Pediatrics 2001;107:1081-1083 10 Spentzas T, Minarik M, Patters AB, et al Children with respiratory distress treated with high-flow nasal cannula J Intensive Care Med 2009;24:323-328 11 Kubicka ZJ, Limauro J, Darnall RA Heated, humidified high-flow nasal cannula therapy: yet another way to deliver continuous positive airway pressure? Pediatrics 2008;121:82-88 12 Wheeler M, Roth AG, Dunham ME, et al A bronchoscopic, computer-assisted examination of the changes in dimension of the infant tracheal lumen with changes in head position: implications for emergency airway management Anesthesiology 1998;88:1183-1187 13 Rose DK, Froese AB The regulation of PaCO2 during controlled ventilation of children with a T-piece Can Anaesth Soc J 1979;26: 104-113 14 Waters DJ, Mapleson WW Rebreathing during controlled respiration with various semiclosed anaesthetic systems Br J Anaesth 1961;33:374-381 15 Abel JG, Salerno TA, Panos A, et al Cardiovascular effects of positive pressure ventilation in humans Ann Thorac Surg 1987;43(2):198-206 16 Aubier M, Viires N, Syllie G, et al Respiratory muscle contribution to lactic acidosis in low cardiac output Am Rev Respir Dis 1982; 126:648-652 17 Field S, Kelly SM, Macklem PT The oxygen cost of breathing in patients with cardiorespiratory disease Am Rev Respir Dis 1982;126:9-13 18 Räsänen J Conventional and high frequency controlled mechanical ventilation in patients with left ventricular dysfunction and pulmonary edema Chest 1987;91:225-229 19 Naughton MT, Rahman MA, Hara K, et al Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with congestive heart failure Circulation 1995;91:1725-1731 20 Kaye DM, Mansfield D, Naughton MT Continuous positive airway pressure decreases myocardial oxygen consumption in heart failure Clin Sci 2004;106:599-603 21 MacDuff A, Grant IS Critical care management of neuromuscular disease, including long-term ventilation Curr Opin Crit Care 2003; 9:106-112 22 Robotham JL A physiological approach to hemidiaphragm paralysis Crit Care Med 1979;7:563-566 23 Muller N, Volgyesi G, Bryan MH, et al The consequences of diaphragmatic muscle fatigue in the newborn infant J Pediatr 1979;95:793-797 24 Le Souef PN, England SJ, Stogryn HA, et al Comparison of diaphragmatic fatigue in newborn and older rabbits J Appl Physiol 1988;65:1040-1044 25 Watchko JF, Mayock DE, Standaert TA, et al The ventilatory pump: neonatal and developmental issues Adv Pediatr 1991;38:109-134 26 Gaultier C Respiratory muscle function in infants Eur Respir J 1995;8:150-153 27 de Leeuw M, Williams JM, Freedom RM, et al Impact of diaphragmatic paralysis after cardiothoracic surgery in children J Thorac Cardiovasc Surg 1999;118:510-517 28 Bach JR, Niranjan V, Weaver B Spinal muscular atrophy type 1: a noninvasive respiratory management approach Chest 2000;117:1100-1105 29 Kaplan JD, Schuster DP Physiologic consequences of tracheal intubation Clin Chest Med 1991;12:425-432 30 Kovac AL Controlling the hemodynamic response to laryngoscopy and endotracheal intubation J Clin Anesth 1996;8:63-79 31 Wicks TC The pharmacology of rocuronium bromide (ORG 9426) AANA J 1994;62:33-38 32 Durand M, Sangha B, Cabal LA, et al Cardiopulmonary and intracranial pressure changes related to endotracheal suctioning in preterm infants Crit Care Med 1989;17:506-510 33 Marshall TA, Deeder R, Pai S, et al Physiologic changes associated with endotracheal intubation in preterm infants Crit Care Med 1984;12:501-503 34 Bode H, Ummenhofer W, Frei F Effects of laryngoscopy and tracheal intubation on cerebral and systemic haemodynamics in children under different protocols of anaesthesia Eur J Pediatr 1993;152:905-908 35 Fanconi S, Duc G Intratracheal suctioning in sick preterm infants: prevention of intracranial hypertension and cerebral hypoperfusion by muscle paralysis Pediatrics 1987;79:538-543 36 Friesen RH, Honda AT, Thieme RE Changes in anterior fontanel pressure in preterm neonates during tracheal intubation Anesth Analg 1987;66:874-878 37 Ninan A, O’Donnell M, Hamilton K, et al Physiologic changes induced by endotracheal instillation and suctioning in critically ill preterm infants with and without sedation Am J Perinatol 1986;3:94-97 38 Barrington KJ, Finer NN, Etches PC Succinylcholine and atropine for premedication of the newborn infant before nasotracheal intubation: a randomized, controlled trial Crit Care Med 1989;17:1293-1296 39 DeBoer SL, Peterson LV Sedation for nonemergent neonatal intubation Neonatal Netw 2001;20:19-23 40 Gentz BA, Shupak RC, Bhatt SB, et al Carbon dioxide dynamics during apneic oxygenation: the effects of preceding hypocapnia J Clin Anesth 1998;10:189-194 41 Patel R, Lenczyk M, Hannallah RS, McGill WA Age and onset of desaturation in apnoeic children Can J Anaesth 1994;41:771-774 42 Millar C, Bissonnette B Awake intubation increases intracranial pressure without affecting cerebral blood flow velocity in infants Can J Anaesth 1994;41:281-287 43 Stow PJ, McLeod ME, Burrows FA, et al Anterior fontanelle pressure responses to tracheal intubation in the awake and anaesthetized infant Br J Anaesth 1988;60:167-170 44 de Beer D, Bingham R The child with facial abnormalities Curr Opin Anaesthesiol 2011;24:282-288 45 Christianson L Anesthesia for major craniofacial operations Int Anesthesiol Clin 1985;23:117-148 46 Mace SE Challenges and advances in intubation: airway evaluation and controversies with intubation Emerg Med Clin North Am 2008;26:977-1000 47 Engelhardt T, Weiss M A child with a difficult airway: what I next? Curr Opin Anaesthesiol 2012;25:326-332 48 Russo SG, Becke K Expected difficult airway in children Curr Opin Anaesthesiol 2015;28:321-326 49 Sullivan KJ, Kissoon N Securing the child’s airway in the emergency department Pediatr Emerg Care 2002;18:108-121 e2 50 Walker RW Management of the difficult airway in children J R Soc Med 2001;94:341-344 51 Mallampati SR, Gatt SP, Gugino LD, et al A clinical sign to predict difficult tracheal intubation—a prospective study Can J Anaesth 1985;32:429-434 52 Nykiel-Bailey SM, McAllister JD, Schrock CR, et al Difficult airway consultation service for children: steps to implement and preliminary results Paediatr Anaesth 2015;25:363-371 53 Apfelbaum JL, Hagberg CA, Caplan RA, et al Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway Anesthesiology 2013;118(2):251-270 54 Janz DR, Semler MW, Joffe AM, et al A multicenter randomized trial of a checklist for endotracheal intubation of critically Ill adults Chest 2018;53(4):816-824 55 Smith KA, High K, Collins SP, Self WH A preprocedural checklist improves the safety of emergency department intubation of trauma patients Acad Emerg Med 2015;22(8):989-992 56 Varghese E, Kundu R Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children? Paediatr Anaesth 2014;24:825-829 57 Bhardwaj N Pediatric cuffed endotracheal tubes J Anaesthesiol Clin Pharmacol 2013;29(1):13-18 58 Deakers TW, Reynolds G, Stretton M, et al Cuffed endotracheal tubes in pediatric intensive care J Pediatr 1994;125:57-62 59 Newth CJ, Rachman B, Patel N, et al The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care J Pediatr 2004;144:333-337 60 Shi F, Xiao Y, Xiong W, et al Cuffed versus uncuffed endotracheal tubes in children: a meta-analysis J Anesth 2016;30:3-11 61 Litman RS, Maxwell LG Cuffed versus un-cuffed endotracheal tubes in pediatric anesthesia: the debate should finally end Anesthesiology 2013;118:500-501 62 Fine GF, Borland LM The future of the cuffed endotracheal tube Paediatr Anaesth 2004;14:38-42 63 Mhanna MJ, Zamel YB, Tichy CM, et al The “air leak” test around the endotracheal tube, as a predictor of postextubation stridor, is age dependent in children Crit Care Med 2002;30:2639-2643 64 Bledsoe GH, Schexnayder SM Pediatric rapid sequence intubation: a review Pediatr Emerg Care 2004;20:339-344 65 McAllister JD, Gnauck KA Rapid sequence intubation of the pediatric patient Fundamentals of practice Pediatr Clin North Am 1999;46:1249-1284 66 Sagarin MJ, Chiang V, Sakles JC Rapid sequence intubation for pediatric emergency airway management Pediatr Emerg Care 2002;18:417-423 67 Whyte S, Birrell G, Wyllie J Premedication before intubation in UK neonatal units Arch Dis Child Fetal Neonatal Ed 2000;82:F38-F41 68 Cools F, Offringa M Neuromuscular paralysis for newborn infants receiving mechanical ventilation Cochrane Database Syst Rev 2000; (4):CD002773 69 Jones P, Dauger S, Denjoy I, et al The effect of atropine on rhythm and conduction disturbances during 322 critical care intubations Pediatr Crit Care Med 2013;14:e289-e297 70 Shaffner DH The continuing controversy about the use of atropine before laryngoscopy and tracheal intubation in children Pediatr Crit Care Med 2013;14:651-653 71 American Heart Association Pediatric Advanced Life Support (PALS) Provider Manual (Professional) Dallas: American Heart Association; 2011:205-206 72 Sokolove PE, Price DD, Okada P The safety of etomidate for emergency rapid sequence intubation of pediatric patients Pediatr Emerg Care 2000;16:18-21 73 Rothermel LK Newer pharmacologic agents for procedural sedation of children in the emergency department—etomidate and propofol Curr Opin Pediatr 2003;15:200-203 74 Wagner RL, White PF, Kan PB, et al Inhibition of adrenal steroidogenesis by the anesthetic etomidate N Engl J Med 1984;310:1415-1421 75 Schenarts CL, Burton JH, Riker RR Adrenocortical dysfunction following etomidate induction in emergency department patients Acad Emerg Med 2001;8:1-7 76 Annane D, Sebille V, Bellissant E Corticosteroids for patients with septic shock JAMA 2003;289:43-44 77 Annane D ICU physicians should abandon the use of etomidate! Intensive Care Med 2005;31:325-326 78 Jackson Jr WL Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock? A critical appraisal Chest 2005;127:1031-1038 79 Fragen RJ, Shanks CA, Molteni A Effect on plasma cortisol concentrations of a single induction dose of etomidate or thiopentone Lancet 2005;2:625 80 De Jong M, Beishuizen A, Spijkstra J, et al Relative adrenal insufficiency as a predictor of disease severity, mortality, and beneficial effects of corticosteroid treatment in septic shock Crit Care Med 2007;35:1896-1903 81 Jabre P, Combes X, Lapostolle F, et al Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial Lancet 2009;374:293-300 82 Sacchetti A Etomidate: not worth the risk in septic patients Ann Emerg Med 2008;52:14-16 83 Walls RM, Murphy MF Clinical controversies: etomidate as an induction agent for endotracheal intubation in patients with sepsis: continue to use etomidate for intubation of patients with septic shock Ann Emerg Med 2008;52:13-14 84 Vinclair M, Broux C, Faure P, et al Duration of adrenal inhibition following a single dose of etomidate in critically ill patients Intensive Care Med 2008;34:714-719 85 Chan CM, Mitchell AL, Shorr AF Etomidate is associated with mortality and adrenal insufficiency in sepsis: a meta-analysis Crit Care Med 2012;40:2945-2953 86 Jung B, Clavieras N, Nougaret S, et al Effects of etomidate on complications related to intubation and on mortality in septic shock patients treated with hydrocortisone: a propensity score analysis Crit Care 2012;16:R224 87 Griesdale DE Etomidate for intubation of patients who have sepsis or septic shock–where we go from here? Crit Care 2012;16:189 88 Slonim AD, Ognibene FP Sedation for pediatric procedures, using ketamine and midazolam, in a primarily adult intensive care unit: a retrospective evaluation Crit Care Med 1998;26:1900-1904 89 Green SM, Denmark TK, Cline J, et al Ketamine sedation for pediatric critical care procedures Pediatr Emerg Care 2001;17:244248 90 Tarquinio KM, Howell JD, Montgomery V, et al Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study Pediatr Crit Care Med 2015;16:210-218 91 Evers AS, Crowder CM, Balser JR General anesthetics In: Brunton L, Lazo J, Parker K, et al, eds Goodman and Gilman’s Pharmacological Basis of Therapeutics 11th ed New York, NY: McGraw Hill; 2006:352 92 Bourgoin A, Albanese J, Wereszczynski N, et al Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil Crit Care Med 2003;31:711-717 93 Zeiler FA, Teitelbaum J, West M, Gillman LM The ketamine effect on ICP in traumatic brain injury Neurocrit Care 2014;21:163-173 94 Zeiler FA, Teitelbaum J, West M, Gillman LM The ketamine effect on intracranial pressure in nontraumatic neurological illness J Crit Care 2014;29:1096-1106 95 Kennedy RM, McAllister JD Midazolam with ketamine: who benefits? Ann Emerg Med 2000;35:297-299 96 Kennedy RM, Porter FL, Miller JP, et al Comparison of fentanyl/ midazolam with ketamine/midazolam for pediatric orthopedic emergencies Pediatrics 1998;102:956-963 97 Parker RI, Mahan RA, Giugliano D, et al Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children Pediatrics 1997;99:427-431 ... spontaneous breathing when a high-flow nasal cannula was in place.249 Similarly, a study in children showed that oxygenation was maintained by use of a high-flow nasal cannula in spontaneously breathing... extreme hyperkalemia and resulting dysrhythmias or cardiac arrest after receiving succinylcholine This response occurs 1533 from approximately 48 hours to to months after injury Often, cervical... referral for cervical spine instability in these patients.238 The ideal approach to intubation in this setting is still being debated.239–242 Evidence in cadavers indicates that typical airway maneuvers