FRCA Notes

Paediatric Rapid Sequence Induction

Resources

Issues with 'classic' RSI in the paediatric population
May increase patient distress
↓ incidence of aspiration in paediatric patients
Fewer deleterious effects from pulmonary aspiration if it does occur
↑ risk of hypoxia, due to ↑metabolic demand, ↓ FRC & ↑ closing capacity
It may be difficult to pre-oxygenate adequately due to poor patient compliance
Even adequate pre-oxygenation may add little in terms of oxygen reserve
Cricoid pressure significantly hinders laryngoscopy due to altered anatomy
May be difficult to obtain IV access

Aspiration

  • Incidence of aspiration in paediatrics is approximately 1 in 5,000
  • Often the sequelae are less significant than in adult patients
  • Paediatric patients at higher risk include:
GI factors Anaesthetic factors Other factors
↑ intra-abdominal pressure Inadequate depth of anaesthesia Sepsis
Obesity Gastric distension from BVM Renal failure
Existing GORD
Use of opioids pre-operatively
Intra-abdominal pathology

Other

  • Saturations <90% (3.6%)
  • Saturations <80% (1.7%)
  • Hypotension <70mmHg (0.8%)
  • Bradycardia (0.5%)

  • Properly managed cuffed ETTs are safe in paediatric populations
  • Recommendations
    • Use an uncuffed tube if child <2.5kg - 3kg in weight
    • If cuffed ETT is used, ensure there is a leak prior to cuff inflation; if not, down-size the tube
    • If cuffed ETT is used, always inflate the cuff
    • Always check the cuff pressure using a manometer and maintain <20cmH2O

  • Continuous aspiration of NG tube, if present
  • Avoid cricoid pressure
    • Cricoid cartilage is smaller, harder to locate and, when pressed, reduces LOS tone and increases risk of passive aspiration
    • Increases patient distress

  • 20° head up position during preoxygenation and induction
  • Gentle ventilation at 10 - 12cmH2O pressure to avoid hypoxia & hypercapnoea
  • Titrated induction agent to deep anaesthesia
  • Non-depolarising neuromuscular blocking agent titrated to a ToF
  • Only intubate after no response to ToF on a nerve stimulator