Intubation Facilitated by Sedation (Paediatric)
 
IFS Indications
GCS <10 due to:
Respiratory failure
- Unresponsive to non-invasive ventilation and drug therapy		 DKA
- Diabetic Ketoacidosis with BGL reading “High”
Near drowning or brief cardiac arrest Status epilepticus
   
General Precautions
Time to intubation at hospital versus time to intubate at scene
Advanced Care Plan / Refusal of Medical Treatment document specifies “Not for Intubation”
   
IFS Precautions
Anticipation of difficulty with BVM ventilation
Anticipation of a difficult intubation, e.g. upper airway obstruction, facial trauma
In general if transport time <10min then no IFS
   
IFS Contraindications
Clinical situations where failed intubation drill would not be feasible such as upper airway obstruction
No functional electronic capnograph
Coma due to neurological injury (TBI, intracranial haemorrhage)
   
General Preparations
Position Pt. If a cervical collar is fitted it should be opened while maintaining manual cervical support
Pre-oxygenate with 100% O2 and electronic capnograph attached
Ensure pulse oximeter and cardiac monitor are functional
Prepare equipment and assistance
- Suction
- ETT (plus one size smaller and one size larger than predicted immediately available) with introducer
- Oesophageal Detector Device (ODD).
- Ensure equipment for a difficult/failed intubation is immediately available, including bougie, LMA, cricothyroidotomy kit
- Mark cricothyroid membrane as necessary
- Brief assistant to provide cricoid pressure, where appropriate
- If suspected spinal injury, where possible a second assistant should be available to stabilise the head and neck
Ensure functional and secure IV access
   
IFS Preparations
Pre-hydrate with Normal Saline fluid bolus 10 ml/kg IV unless APO
If Pt hypotensive and/or tachycardic, follow relevant CPG in conjunction with the intubation process
Draw up and label drugs as appropriate
   
ETT Size/Placement
Age
ETT Size
Length at Lips
Newborn
3.0mm
9.5cm
6mth
3.5mm
11.0cm
12mth
4.0mm
12.0cm
>12mth age/4 + 4mm age/2 + 12cm
Children under the age of 10 years should be intubated with an uncuffed endotracheal tube – the largest uncuffed ETT available is a size 6.5mm.
If in doubt, refer to paediatric graph. The correct size tube should allow a small leak around the tube with positive pressure but not so great as to make ventilation inadequate. A closer fitting tube may be necessary when ventilating stiff lungs, e.g. near drowning.
ETT Suction
This may be necessary to remove tracheal secretions or aspirated material
ETT Size Suction Catheter Size
3.0mm 6 FG
3.5 – 5.5mm 8 FG
6.0mm
10 FG
   
IFS Sedation
• Fentanyl 2mcg/kg IV
• Midazolam 0.2mg/kg IV
   
Insertion of ETT
Observe passage of ETT through cords noting AS standard markings and grade of view
Check ETT position using Oesophageal Detector Device (ODD).
Inflate cuff.
Confirm tracheal placement via capnometry.
Exclude right main bronchus intubation by performing the cuff palpation (“tracheal squash”) test and by comparing air entry at the axillae.
Note length of ETT at lips/teeth.
Cuff Palpation
Auscultate chest/epigastrium
- Chest rise and fall, bag movement, SpO2, colour, tube misting
Note supplemental cues of correct placement (e.g. tube “misting”, bag movement in the spontaneously ventilating Pt, improved oxygen saturation and colour).
Secure the ETT and insert a bite block if required.
If unable to intubate after ensuring correct technique and problem solving then proceed to Failed Intubation Drill
If Capnography or colourimetric CO2 detection is negative (including Pts in cardiac arrest), the ETT must be removed.
If there is ANY doubt about tracheal placement, the ETT must be removed
If unable to intubate due to excessive tone
If GR 1 or 2 view but respiratory effort of airway reflexes are preventing intubation
- Repeat same dose of sedation and reattempt intubation once only
If GR 3 or 4 view
- Proceed to Failed Intubation Drill
   
Successful Intubation?
                        Yes   No  
                       
     
Cricothyroidotomy
(on consult or if authorised)
             
             
   
Does Pt's require sedation or paralysis to maintain intubation and ventilation?
    Yes     No
Yes
    
Post Intubation Sedation
     
Post Intubation Paralysis
(on consult only)
Restlessness/signs of under sedation in the absence of other noxious stimuli
- e.g. ETT too deep/irritating, occult pain
      
Where sedation alone is ineffective at maintaining
intubation or allowing adequate ventilation/oxygenation
As prescribed for interhospital transfer
 
All Pts receiving paralysis MUST receive ongoing sedation
The ETT must be secured and tracheal placement reconfirmed with electronic capnography
C/I for Pt in Status epilepticus
Sedate as per Post Intubation Sedation
Pancuronium 0.1mg/kg IV - (consult only)
- Repeat if evidence of returning muscular activity
(movement, chewing, cough, gag, curare cleft)
Signs of inadequate sedation
Non Paralysed:
- As per Paralysed
- Cough/gag/movement up together
Pt Paralysed Pt:
- HR and BP trending
- Tearing
- Diaphoresis		      
Morphine/Midazolam infusion 0.1-0.2mg/kg/hr IV
- Repeat 0.1mg/kg IV boluses as required
Until Morphine/Midazolam infusion established:
- Midazolam 0.1mg/kg IV as required or
- Midazolam and Morphine 0.1mg/kg IV each drug
   
   
         
 
Care / Ventilation of the Intubated Pt
ETT checks with each Pt movement
Provide circulatory support if hypotension present
Use colourimetric capnometry if capnography fails
Suction ETT and oropharynx
Insert OG/NG tube
Ventilate tidal volume10ml/kg, EtCO2 30-35mmHg if appropriate to Pt condition
Disconnect and hold ETT during transfers
Specific instructions as per General Care of the Intubated Pt
   
General Care
Cervical collars should be placed on all intubated children over the age of 4 where practicable.
Reconfirm tracheal placement using EtCO2 after every Pt movement. Disconnect and hold ETT during all transfers.
If electronic capnography fails after intubation, use colourimetric capnometry.
Suction ETT and oropharynx in all Pts.
Insert orogastric or nasogastric tube, aspirate and connect to drainage bag.
Ventilate using 100% oxygen and tidal volume of 10ml/kg. Aim to maintain SpO2 > 95% and EtCO2 at 30-35mmHg (except asthma where a higher EtCO2 maybe permitted, tricyclic OD where the target is 20 - 25mmHg, and DKA where the EtCO2 should be maintained at the level detected immediately post-intubation, with a max. of 25mmHg).
Document all checks and observations made to confirm correct ETT placement.