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Comparison of drugs used for intubation of pediatric trauma patients
YJPSU-59585; No of Pages 4 Journal of Pediatric Surgery xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Comparison of drugs used for intubation of pediatric trauma patients Martina Mudri a, Andrew Williams a, Fran Priestap b, Jacob Davidson c, Neil Merritt c,⁎ a b c
Division of General Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada Division of Paediatric General Surgery, Children's Hospital London Health Science Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
a r t i c l e
i n f o
Article history: Received 8 January 2020 Accepted 25 January 2020 Available online xxxx Key words: Rapid sequence intubation (RSI) Propofol Trauma Pediatric Traumatic brain injury (TBI)
a b s t r a c t Purpose: Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but this has not been examined in the pediatric population. This descriptive study compares the outcomes associated with intubation drugs used in pediatric traumatic brain injury (TBI) patients. Methods: A retrospective chart review and descriptive analysis of intubated TBI patients, ages 0–17, admitted to Children's Hospital London Health Sciences Centre (LHSC) from January 2006–December 2016 was performed. Results: Out of 259 patients intubated, complete data was available for 107 cases. Average injury severity score was 28; 46 were intubated at LHSC, 55 at primary care site, and 6 on scene. Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5%. Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used intubation drugs. Paralytics were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index was increased as a result of worsening hypotension. Mean total hospital length of stay was 21 days with 7.5 days in ICU. Survival was 87%. Conclusion: Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used and is potentially associated with poorer clinical outcomes. Type of Study: Retrospective. Level of Evidence: IV © 2020 Elsevier Inc. All rights reserved.
Airway compromise is a common cause of death and severe morbidity in the trauma population [1]. Airway management is therefore a critical step in the treatment of pediatric trauma patients [2]. Rapid sequence intubation (RSI) is the recommended method of emergency intubation in trauma patients [3, 4]. RSI is an organized approach to emergency intubation that encompasses preoxygenation, rapid sedation, paralysis, and intubation [1]. RSI allows for intubation to occur quickly while minimizing the risk of aspiration [1, 3, 5]. Induction agents such as propofol are used to provide rapid sedation for this process [1]. In the pediatric population, blunt head trauma is the most common indication for emergency endotracheal intubation [6]. In this high-risk population, hemodynamic instability leads to poorer clinical outcomes. Trauma patients are already at risk of hypotension due to hemorrhagic shock. In traumatic brain injury (TBI) patients, hypotension may lead to secondary brain injury due to inadequate brain perfusion [6]. The choice of induction agents used for RSI affects hemodynamic stability and clinical outcomes in patients [7–9]. Post-intubation hypotension is
associated with increased morbidity and mortality [7]. However, there is currently limited research to support recommendations for drugs used for RSI. Propofol is a popular induction agent used for intubation due to its rapid onset of action, short duration, and ease of titratability [1]. It has been used and studied in procedural sedation [10–12], and has been effective when used alone and also in combination with other drugs such as ketamine [13–15]. However, the use of propofol was also found to be associated with several complications including postintubation hypotension and respiratory depression [3, 16, 17]. Despite the popularity of propofol in RSI for pediatric trauma patients, the outcomes of its use as an induction agent are yet to be studied. Therefore, the objective of this research was to determine the safety of propofol compared to other agents used in RSI for pediatric trauma patients with traumatic brain injury. The primary outcome measured is mortality. Secondary outcomes include hemodynamic stability measured by the Pediatric Adjusted Shock Index (PASI) and first pass success rate.
⁎ Corresponding author at: Pediatric Surgeon and Pediatric Trauma Program Director, Children's Hospital, London Health Sciences Centre, Rm B1-188, 800 Commissioners Road East, London, Ontario, Canada, N6C 2V3. Tel.: +1 519 685 8401; fax: +1 519 685 8421. E-mail address: [email protected] (N. Merritt).
1. Materials and methods This research study was approved by the Research Ethics Board (REB #110558). The London Health Sciences Centre (LHSC) Trauma Program
https://doi.org/10.1016/j.jpedsurg.2020.01.041 0022-3468/© 2020 Elsevier Inc. All rights reserved.
Please cite this article as: M. Mudri, A. Williams, F. Priestap, et al., Comparison of drugs used for intubation of pediatric trauma patients, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2020.01.041
2
M. Mudri et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
was used to identify patient records for the study. Inclusion criteria included intubated pediatric TBI patients from ages 0–17 admitted to Children's Hospital at LHSC from January 2006–December 2016. Exclusion criteria included pediatric trauma patients without head injury and those who were not intubated at the time of their trauma resuscitation. A retrospective review was then performed of paper charts obtained from Health Records. Variables analyzed included gender, intubation site, total hospital length of stay (LOS), total ICU LOS, injury severity score (ISS), survival rate, first-pass intubation rate, induction agent used, paralytic agent used, heart rate, blood pressure. PASI was calculated by dividing change in heart rate over change in blood pressure. Descriptive statistical analysis was performed. Categorical data is presented as numbers and percentages. Continuous data elements are reported as mean and standard deviation or median and interquartile range as appropriate. 2. Results We identified 259 patients that were intubated for TBI during the study period using the LHSC Trauma Program database (Fig. 1). Health Records located 239 paper charts which were reviewed. Fourteen paper charts were not located, and therefore excluded from the study. Out of 239 paper charts reviewed, data regarding intubation was available for 107 cases, 67 male and 40 female (Fig. 1). One hundred thirtyeight charts had missing data regarding intubation and were therefore excluded from the study. There were a total of 152 cases excluded due to missing data. Out of 107 TBI patients, 46 were intubated at LHSC, 55 at the primary care site, and 6 on scene (Fig. 1). Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5% (Fig. 1). Mean total hospital length of stay (LOS) was 21 days (IQR 7–25) with 7.5 days (IQR 2.0–11.0) in ICU (Fig. 1). The average injury severity score (ISS) was 28 (+/− 9.2) (Fig. 1). The mean survival was 87% (Fig. 1). Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used single intubation drugs (Fig. 2). Combinations included: etomidate/midazolam (n = 4), ketamine/midazolam (n = 3), propofol/midazolam (n = 2), and propofol/ketamine/midazolam (n = 1). No drugs were used for
Fig. 2. Induction agents used for RSI. Most commonly used were midazolam (n = 31), no drug (n = 24), propofol (n = 21), etomidate (n = 13), and ketamine (n = 7). Paralytics were used 50% of the time overall for intubation.
intubation of 24 patients (Fig. 2). There was one patient that received fentanyl and no other drugs. Paralytics, either rocuronium or succinylcholine, were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index (PASI) was increased as a result of worsening hypotension (Fig. 3). We were not able to obtain information from paper charts regarding intubation agents, number of attempts, or clinical outcomes such as hemodynamic stability for a total of 152 patients, 97 male and 55 female (Fig. 4). From 2006 to 2016, between 9 and 19 cases per year had missing data. Using the LHSC Trauma Program database, we were able to determine that 30 of these cases were intubated at LHSC, 105 at the
Fig. 1. Flow chart of intubated pediatric TRI patients.
Please cite this article as: M. Mudri, A. Williams, F. Priestap, et al., Comparison of drugs used for intubation of pediatric trauma patients, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2020.01.041
M. Mudri et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
3
Fig. 3. Pediatric adjusted shock index and blood pressure trends. The PASI increased with use of propofol in RSI. Blood pressure trend decreased with Use of propofol.
primary hospital, 1 at a secondary hospital, and 16 on scene (Fig. 4). Median total hospital LOS was 10 days (IQR 4.0–19.0). Median ICU LOS was 3 days (IQR 2.0–7.5) (Fig. 4). The mean ISS was 25.2 (+/−13.5) (Fig. 4). The mean survival rate was 73.7% (Fig. 4). 3. Discussion Propofol is a commonly used induction agent for RSI [3, 7]. However, it can also lead to complications that may lead to increased morbidity and mortality in high-risk populations with TBI [3]. Our findings were consistent with the literature in that propofol was a popular choice of
induction agent for intubation. Propofol was the second-most commonly used induction agent for RSI in pediatric TBI patients at our institution. Propofol has been studied in procedural sedation [10–12], and has proven to be effective when used alone or in combination with other drugs such as ketamine [13–15]. At our institution, propofol was used with ketamine, midazolam and etomidate. Limitations of this study include the retrospective data collection, missing data in paper charts, and inability to perform statistical analysis due to low sample size. The data collection process highlighted the issues with record keeping in paper charts. Over 50% of charts had missing information regarding intubation that was critical to this study. This
Fig. 4. Flow chart of excluded pediatric TBI intubations.
Please cite this article as: M. Mudri, A. Williams, F. Priestap, et al., Comparison of drugs used for intubation of pediatric trauma patients, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2020.01.041
4
M. Mudri et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
resulted in the inability to perform inferential statistical analysis. However, the descriptive analysis performed provided critical information that will be the stepping stone to future research in the area. In the literature, propofol was found to be more effective than other agents for neonatal nasal endotracheal intubation [18]. Another randomized trial by Shaikh et al. showed that opioids and propofol were the most popular combination to use for endotracheal intubation prior to elective surgical procedures in children, and that the use of paralytic agents was not necessary for successful intubation [19]. The first pass success rate of intubation was 89%, which is higher than the 78% successful first attempt intubation rate that is reported in the literature [20, 21]. Despite its popularity as an induction agent, the use of propofol for intubation is associated with several complications including laryngospasm, bradycardia, and dysrhythmia [16]. There is also a dose dependent risk of hypotension and respiratory depression with propofol use due to its calcium channel and β-receptor antagonist properties [3, 15]. Furthermore, other induction agents can be used effectively for intubation with fewer risks of complication. Our study showed an increased trend in PASI with the use of propofol for RSI. The increased PASI was due to post-intubation hypotension following the use of propofol for induction. These findings are in keeping with a recent retrospective study by Dietrich et al., where the use of propofol in RSI was found to increase the risk of hypotension compared to the use of other drugs such as etomidate and midazolam in adult trauma patients [3]. Induction agents such as etomidate have been successfully used in RSI with favorable outcomes even in those patients in shock [9]. 4. Conclusion Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used at our institution and is potentially associated with poorer clinical outcomes. This study also highlighted the challenges of medical record-keeping for critical events such as intubation in trauma resuscitation. Next steps will include a quality assurance project to address this study's limitations with the goal of standardizing record keeping of intubation procedures during trauma resuscitation. Standardized record keeping is an important part of medical care because it ensures documentation of key events. In addition, future work may include creating a protocol to standardize the use of induction agents used for RSI. The goal of such a protocol would be to prevent complications associated with the use of propofol and recommend other drugs with better safety profiles. Competing Interests Statement The authors of this manuscript have competing interests to declare. References [1] Gerardi MJ, Sacchetti AD, Cantor RM, et al. Rapid-sequence intubation of the pediatric patient. Ann Emerg Med 1996;28(1):55–74.
[2] McFadyen JG, Ramaiah R, Bhananker SM. Initial assessment and management of pediatric trauma patients. Int J Crit Illn Inj Sci 2012;2:121–7. https://doi.org/10.4103/ 2229-5151.100888. [3] Dietrich SK, Mixon MA, Rogoszewski RJ, et al. Hemodynamic effects of propofol for induction of rapid sequence intubation in traumatically injured patients. Am Surg 2018;84:1504–8. [4] Mayglothling J, Duane TM, Gibbs M, et al. Emergency tracheal intubation immediately following traumatic injury: an eastern association for the surgery of trauma practice management guideline. J Trauma Acute Care Surg 2012. https://doi.org/ 10.1097/TA.0b013e31827018a5. [5] Bano S, Akhtar S, Zia N, et al. Pediatric endotracheal intubations for airway management in the emergency department. Pediatr Emerg Care 2012;28:1129–31. https:// doi.org/10.1097/PEC.0b013e3182713316 LK - http://sfx.hul.harvard.edu/sfx_local? sid=EMBASE&issn=07495161&id=doi:10.1097%2FPEC. 0b013e3182713316&atitle=Pediatric+endotracheal+intubations+for+airway+ management+in+the+emergency+department&stitle=Pediatr.+Emerg. +Care&title=Pediatric+Emergency+Care&volume=28&issue=11&spage= 1129&epage=1131&aulast=Bano&aufirst=Surraiya&auinit=S.&aufull=Bano+S. &coden=PECAE&isbn=&pages=1129-1131&date=2012&auinit1=S&auinitm=. [6] Nakayama DK, Gardner MJ, Rowe MI. Emergency endotracheal intubation in pediatric trauma. Ann Surg 1990;211:218–23. https://doi.org/10.1097/00000658199002000-00015. [7] Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations – Part I. J Intensive Care Med 2007;22:157–65. https://doi.org/10.1177/ 0885066607299525. [8] Sivilotti MLA, Ducharme J. Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: the SHRED study. Ann Emerg Med 1998;31:313–24. https://doi.org/10.1016/S01960644(98)70341-5. [9] Zuckerbraun NS, Pitetti RD, Herr SM, et al. Use of etomidate as an induction agent for rapid sequence intubation in a pediatric emergency department. Acad Emerg Med 2006;13:602–9. https://doi.org/10.1197/j.aem.2005.12.026. [10] Skokan EG, Pribble C, Bassett KE, et al. Use of propofol sedation in a pediatric emergency department: a prospective study. Clin Pediatr (Phila) 2001;40:663–71. https://doi.org/10.1177/000992280104001204. [11] Jasiak KD, Phan H, Christich AC, et al. Induction dose of propofol for pediatric patients undergoing procedural. Pediatr Emerg Care 2012;28:440–2. [12] Mallory MD, Baxter AL, Yanosky DJ, et al. Emergency physicianadministered propofol sedation: A report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med 2011;57:462–8 e1 https://doi.org/10.1016/j. annemergmed.2011.03.008. [13] Andolfatto G, Abu-Laban RB, Zed PJ, et al. Ketamine-propofol combination (Ketofol) versus propofol alone for emergency department procedural sedation and analgesia: A randomized double-blind trial. Ann Emerg Med 2012;59:504–12 e2 https://doi. org/10.1016/j.annemergmed.2012.01.017. [14] David H, Shipp J. A randomized controlled trial of ketamine/propofol versus propofol alone for emergency department procedural sedation. Ann Emerg Med 2011;57: 435–41. https://doi.org/10.1016/j.annemergmed.2010.11.025. [15] Shah A, Mosdossy G, McLeod S, et al. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med 2011;57:425–33. https://doi.org/10.1016/j.annemergmed.2010. 08.032. [16] Aouad MT, Yazbeck-Karam VG, Mallat CE, et al. The effect of adjuvant drugs on the quality of tracheal intubation without muscle relaxants in children: a systematic review of randomized trials. Paediatr Anaesth 2012;22:616–26. https://doi.org/10. 1111/j.1460-9592.2012.03845.x. [17] Stollings JL, Diedrich DA, Oyen LJ, et al. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother 2014; 48:62–76. [18] Abdel-Latif ME, Oei J, Lui K. Propofol Compared With the Morphine, Atropine, and Suxamethonium Regimen as Induction Agents for Neonatal Endotracheal Intubation: A Randomized, Controlled Trial: In Reply. Pediatrics 2007;120(933):246. https://doi.org/10.1542/peds.2007-2352. [19] Shaikh SI, Bellagali VP. Tracheal intubation without neuromuscular block in children. Indian J Anaesth 2010;54:29–34. https://doi.org/10.4103/0019-5049.60493. [20] Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Pediatr Anesth 2014;24:1204–11. [21] Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002;18:417–23.
Please cite this article as: M. Mudri, A. Williams, F. Priestap, et al., Comparison of drugs used for intubation of pediatric trauma patients, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2020.01.041
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Comparison of drugs used for intubation of pediatric trauma patients Martina Mudri a, Andrew Williams a, Fran Priestap b, Jacob Davidson c, Neil Merritt c,⁎ a b c
Division of General Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada Division of Paediatric General Surgery, Children's Hospital London Health Science Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
a r t i c l e
i n f o
Article history: Received 8 January 2020 Accepted 25 January 2020 Available online xxxx Key words: Rapid sequence intubation (RSI) Propofol Trauma Pediatric Traumatic brain injury (TBI)
a b s t r a c t Purpose: Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but this has not been examined in the pediatric population. This descriptive study compares the outcomes associated with intubation drugs used in pediatric traumatic brain injury (TBI) patients. Methods: A retrospective chart review and descriptive analysis of intubated TBI patients, ages 0–17, admitted to Children's Hospital London Health Sciences Centre (LHSC) from January 2006–December 2016 was performed. Results: Out of 259 patients intubated, complete data was available for 107 cases. Average injury severity score was 28; 46 were intubated at LHSC, 55 at primary care site, and 6 on scene. Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5%. Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used intubation drugs. Paralytics were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index was increased as a result of worsening hypotension. Mean total hospital length of stay was 21 days with 7.5 days in ICU. Survival was 87%. Conclusion: Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used and is potentially associated with poorer clinical outcomes. Type of Study: Retrospective. Level of Evidence: IV © 2020 Elsevier Inc. All rights reserved.
Airway compromise is a common cause of death and severe morbidity in the trauma population [1]. Airway management is therefore a critical step in the treatment of pediatric trauma patients [2]. Rapid sequence intubation (RSI) is the recommended method of emergency intubation in trauma patients [3, 4]. RSI is an organized approach to emergency intubation that encompasses preoxygenation, rapid sedation, paralysis, and intubation [1]. RSI allows for intubation to occur quickly while minimizing the risk of aspiration [1, 3, 5]. Induction agents such as propofol are used to provide rapid sedation for this process [1]. In the pediatric population, blunt head trauma is the most common indication for emergency endotracheal intubation [6]. In this high-risk population, hemodynamic instability leads to poorer clinical outcomes. Trauma patients are already at risk of hypotension due to hemorrhagic shock. In traumatic brain injury (TBI) patients, hypotension may lead to secondary brain injury due to inadequate brain perfusion [6]. The choice of induction agents used for RSI affects hemodynamic stability and clinical outcomes in patients [7–9]. Post-intubation hypotension is
associated with increased morbidity and mortality [7]. However, there is currently limited research to support recommendations for drugs used for RSI. Propofol is a popular induction agent used for intubation due to its rapid onset of action, short duration, and ease of titratability [1]. It has been used and studied in procedural sedation [10–12], and has been effective when used alone and also in combination with other drugs such as ketamine [13–15]. However, the use of propofol was also found to be associated with several complications including postintubation hypotension and respiratory depression [3, 16, 17]. Despite the popularity of propofol in RSI for pediatric trauma patients, the outcomes of its use as an induction agent are yet to be studied. Therefore, the objective of this research was to determine the safety of propofol compared to other agents used in RSI for pediatric trauma patients with traumatic brain injury. The primary outcome measured is mortality. Secondary outcomes include hemodynamic stability measured by the Pediatric Adjusted Shock Index (PASI) and first pass success rate.
⁎ Corresponding author at: Pediatric Surgeon and Pediatric Trauma Program Director, Children's Hospital, London Health Sciences Centre, Rm B1-188, 800 Commissioners Road East, London, Ontario, Canada, N6C 2V3. Tel.: +1 519 685 8401; fax: +1 519 685 8421. E-mail address: [email protected] (N. Merritt).
1. Materials and methods This research study was approved by the Research Ethics Board (REB #110558). The London Health Sciences Centre (LHSC) Trauma Program
https://doi.org/10.1016/j.jpedsurg.2020.01.041 0022-3468/© 2020 Elsevier Inc. All rights reserved.
Please cite this article as: M. Mudri, A. Williams, F. Priestap, et al., Comparison of drugs used for intubation of pediatric trauma patients, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2020.01.041
2
M. Mudri et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
was used to identify patient records for the study. Inclusion criteria included intubated pediatric TBI patients from ages 0–17 admitted to Children's Hospital at LHSC from January 2006–December 2016. Exclusion criteria included pediatric trauma patients without head injury and those who were not intubated at the time of their trauma resuscitation. A retrospective review was then performed of paper charts obtained from Health Records. Variables analyzed included gender, intubation site, total hospital length of stay (LOS), total ICU LOS, injury severity score (ISS), survival rate, first-pass intubation rate, induction agent used, paralytic agent used, heart rate, blood pressure. PASI was calculated by dividing change in heart rate over change in blood pressure. Descriptive statistical analysis was performed. Categorical data is presented as numbers and percentages. Continuous data elements are reported as mean and standard deviation or median and interquartile range as appropriate. 2. Results We identified 259 patients that were intubated for TBI during the study period using the LHSC Trauma Program database (Fig. 1). Health Records located 239 paper charts which were reviewed. Fourteen paper charts were not located, and therefore excluded from the study. Out of 239 paper charts reviewed, data regarding intubation was available for 107 cases, 67 male and 40 female (Fig. 1). One hundred thirtyeight charts had missing data regarding intubation and were therefore excluded from the study. There were a total of 152 cases excluded due to missing data. Out of 107 TBI patients, 46 were intubated at LHSC, 55 at the primary care site, and 6 on scene (Fig. 1). Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5% (Fig. 1). Mean total hospital length of stay (LOS) was 21 days (IQR 7–25) with 7.5 days (IQR 2.0–11.0) in ICU (Fig. 1). The average injury severity score (ISS) was 28 (+/− 9.2) (Fig. 1). The mean survival was 87% (Fig. 1). Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used single intubation drugs (Fig. 2). Combinations included: etomidate/midazolam (n = 4), ketamine/midazolam (n = 3), propofol/midazolam (n = 2), and propofol/ketamine/midazolam (n = 1). No drugs were used for
Fig. 2. Induction agents used for RSI. Most commonly used were midazolam (n = 31), no drug (n = 24), propofol (n = 21), etomidate (n = 13), and ketamine (n = 7). Paralytics were used 50% of the time overall for intubation.
intubation of 24 patients (Fig. 2). There was one patient that received fentanyl and no other drugs. Paralytics, either rocuronium or succinylcholine, were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index (PASI) was increased as a result of worsening hypotension (Fig. 3). We were not able to obtain information from paper charts regarding intubation agents, number of attempts, or clinical outcomes such as hemodynamic stability for a total of 152 patients, 97 male and 55 female (Fig. 4). From 2006 to 2016, between 9 and 19 cases per year had missing data. Using the LHSC Trauma Program database, we were able to determine that 30 of these cases were intubated at LHSC, 105 at the
Fig. 1. Flow chart of intubated pediatric TRI patients.
Please cite this article as: M. Mudri, A. Williams, F. Priestap, et al., Comparison of drugs used for intubation of pediatric trauma patients, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2020.01.041
M. Mudri et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
3
Fig. 3. Pediatric adjusted shock index and blood pressure trends. The PASI increased with use of propofol in RSI. Blood pressure trend decreased with Use of propofol.
primary hospital, 1 at a secondary hospital, and 16 on scene (Fig. 4). Median total hospital LOS was 10 days (IQR 4.0–19.0). Median ICU LOS was 3 days (IQR 2.0–7.5) (Fig. 4). The mean ISS was 25.2 (+/−13.5) (Fig. 4). The mean survival rate was 73.7% (Fig. 4). 3. Discussion Propofol is a commonly used induction agent for RSI [3, 7]. However, it can also lead to complications that may lead to increased morbidity and mortality in high-risk populations with TBI [3]. Our findings were consistent with the literature in that propofol was a popular choice of
induction agent for intubation. Propofol was the second-most commonly used induction agent for RSI in pediatric TBI patients at our institution. Propofol has been studied in procedural sedation [10–12], and has proven to be effective when used alone or in combination with other drugs such as ketamine [13–15]. At our institution, propofol was used with ketamine, midazolam and etomidate. Limitations of this study include the retrospective data collection, missing data in paper charts, and inability to perform statistical analysis due to low sample size. The data collection process highlighted the issues with record keeping in paper charts. Over 50% of charts had missing information regarding intubation that was critical to this study. This
Fig. 4. Flow chart of excluded pediatric TBI intubations.
Please cite this article as: M. Mudri, A. Williams, F. Priestap, et al., Comparison of drugs used for intubation of pediatric trauma patients, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2020.01.041
4
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resulted in the inability to perform inferential statistical analysis. However, the descriptive analysis performed provided critical information that will be the stepping stone to future research in the area. In the literature, propofol was found to be more effective than other agents for neonatal nasal endotracheal intubation [18]. Another randomized trial by Shaikh et al. showed that opioids and propofol were the most popular combination to use for endotracheal intubation prior to elective surgical procedures in children, and that the use of paralytic agents was not necessary for successful intubation [19]. The first pass success rate of intubation was 89%, which is higher than the 78% successful first attempt intubation rate that is reported in the literature [20, 21]. Despite its popularity as an induction agent, the use of propofol for intubation is associated with several complications including laryngospasm, bradycardia, and dysrhythmia [16]. There is also a dose dependent risk of hypotension and respiratory depression with propofol use due to its calcium channel and β-receptor antagonist properties [3, 15]. Furthermore, other induction agents can be used effectively for intubation with fewer risks of complication. Our study showed an increased trend in PASI with the use of propofol for RSI. The increased PASI was due to post-intubation hypotension following the use of propofol for induction. These findings are in keeping with a recent retrospective study by Dietrich et al., where the use of propofol in RSI was found to increase the risk of hypotension compared to the use of other drugs such as etomidate and midazolam in adult trauma patients [3]. Induction agents such as etomidate have been successfully used in RSI with favorable outcomes even in those patients in shock [9]. 4. Conclusion Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used at our institution and is potentially associated with poorer clinical outcomes. This study also highlighted the challenges of medical record-keeping for critical events such as intubation in trauma resuscitation. Next steps will include a quality assurance project to address this study's limitations with the goal of standardizing record keeping of intubation procedures during trauma resuscitation. Standardized record keeping is an important part of medical care because it ensures documentation of key events. In addition, future work may include creating a protocol to standardize the use of induction agents used for RSI. The goal of such a protocol would be to prevent complications associated with the use of propofol and recommend other drugs with better safety profiles. Competing Interests Statement The authors of this manuscript have competing interests to declare. References [1] Gerardi MJ, Sacchetti AD, Cantor RM, et al. Rapid-sequence intubation of the pediatric patient. Ann Emerg Med 1996;28(1):55–74.
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Please cite this article as: M. Mudri, A. Williams, F. Priestap, et al., Comparison of drugs used for intubation of pediatric trauma patients, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2020.01.041