Intubation: Before Procedure

Equipment

• Monitoring equipment: pulse oximeter, electrocardiogram (ECG), blood pressure

• Oxygen source: delivered by mask prior to intubation

• Anesthesia type bag: expands when connected to gas flow; various designs available but must have adequate flow through system to prevent rebreathing

• Self-inflating bag: designs vary; many have pressure pop-off at 35 to 45 cm H₂O, so if lungs are severely noncompliant, may not adequately ventilate or oxygenate with this bag or may need to bypass the pop-off

• Endotracheal tubes (ETTs):

• Appropriate estimated size tube: (Age + 16)/4 = Endotracheal tube size

• Adjust for extremes in patient size or known abnormality of tracheal size.

• Tubes are cuffed and noncuffed:

• Cuffed tubes are universally recommended above age 8 years.

• Under age 8 years, most recent recommendations are that cuffed tubes may be used. In the past, cuffed tubes were thought to be unnecessary because of the narrow trachea at the level of the cricoid cartilage and potentially risky because of risk of airway injury. Currently the cuffs are high-volume, low-pressure cuffs that require lower pressure to be effective, therefore decreasing the risk of airway injury. For patients with noncompliant lungs requiring higher airway pressures, the presence of a cuff decreases the air leak, allowing for better lung inflation and recruitment.

• Stylets: available in pediatric and adult sizes; may be needed to help strengthen the pliable ETT to assist in intubation; skill and experience of operator will dictate its usefulness.

• Suction devices: must be sturdy enough to suction very thick secretions in even the smallest infant

• End-tidal CO₂ detector: disposable colorimetric CO₂ detectors are available in pediatric and adult sizes; the weight of the patient will determine the size of the device.

• Means for securing the ETT: either tape or an appropriately sized securement device

• Airway support devices: these may be useful depending on the stability of the airway:

• Oral airways: come in various sizes; poorly tolerated in a conscious patient; may be needed for airway maintenance prior to intubation

• Nasopharyngeal airways: come in various sizes and can relieve nasal and pharyngeal obstruction in conscious patients, including children. The appropriate-sized airway extends from the nares to the tragus of the ear. The diameter should be large enough that it does not cause obstruction and not so large that it causes blanching of the alae nasi, which can lead to necrosis.

• Laryngeal mask airway: can provide immediate airway access and should be available during even nonemergent intubation in the event the airway is difficult to intubate. They come in a variety of sizes appropriate for pediatric patients. The LMA consists of a wide-bore tube with a standard 15-mm adapter at the proximal end for attachment to the circuit or resuscitation bag. The distal end is an elliptical mask that can be inflated and conforms to the shape of the larynx, providing a low-pressure seal for ventilation at the level of the larynx (see Procedure).

• Pharmacologic agents: various sedative and paralytic drugs are available for intubation. There are different conditions for intubation that require certain combinations of drugs for safest and most effective intubation. One must be familiar with the variety of drugs available, including side effects, indications, and contraindications.

• Anticholinergic agents: prevent bradycardia during laryngoscopy and decrease oral secretions

• Sedative agents: in choosing one of these agents, consideration should be given to hemodynamic status, presence of increased ICP, age of patient, underlying chronic medical conditions, and current disease process:

• Anxiolytics including benzodiazepines such as midazolam or lorazepam

• Narcotics including opiates such as fentanyl or morphine

• Anesthetics including ketamine, pentothal, etomidate, or propofol

• Neuromuscular blockers:

• Nondepolarizing agents:

• Amino-steroid agents: vecuronium or rocuronium

• Benzylquinolinium agents: atracurium or cisatracurium

• Depolarizing agents: succinylcholine; there is a U.S. Food and Drug Administration (FDA) warning against its routine use in children because of the frequency and severity of side effects. Although its rapid onset of action in emergencies is felt to be useful, the onset of action is not significantly advantageous over rocuronium, which has fewer side effects.

Anatomy

The pediatric airway changes with age and development and differs from the adult airway in many aspects. Understanding these differences and being aware of the age-related changes are important for optimal airway management. The larynx in children is located higher in the neck, with the epiglottis being at the level of C1 as a neonate and at the level of C3-C4 by 6 months of age, as opposed to the adult, where the larynx is around C5. This more superior position of the larynx creates more acute angulation during laryngoscopy and can make visualization of the glottic opening more difficult. Also, the tongue is located more superiorly and closer to the palate in children than in adults and is larger in relation to the bony structures of the cranium, potentially causing airway obstruction. The narrowest portion of a child’s airway is the subglottic region, whereas the narrowest portion of an adult airway is the vocal cords. This difference has allowed for uncuffed tracheal tubes to be used in infants and young children. Another major difference is that children have a more protuberant occiput, which may cause excessive neck flexion. Finally, the infant’s nares are smaller. Because infants are obligate nasal breathers for the first 6 months of life, occlusion of the nasal passages with secretions, edema, or blood can cause significant resistance to airflow and significantly increase the work of breathing.

Procedure

• Preoxygenate patient; if possible allow the patient to breathe spontaneously on FIO₂ 1.0 or as much as can be delivered in order to maximally increase the patient’s PaO₂ prior to intubation attempt.

• Position patients head; the goal of head positioning is to align the oral, pharyngeal, and laryngeal axes.

• Infants have a large occiput which puts them close to proper alignment, although they may need a roll under the shoulders; care should be taken to avoid overextension of the head, which also malaligns the airway.

• Children should have a roll put under the occiput to put the head in “sniffing” position, which will better align the airway.

• Head extension in both groups better aligns the airway.

• Administer pharmacologic agents:

• Anticholinergic may be delivered first.

• Sedatives are given next, observing closely for changes in respiration and hemodynamics; may need to have airway and breathing supported just with sedative administration.

• Neuromuscular blockade is delivered last and only after determining the airway can be managed with bag and mask; if not, the neuromuscular blocker should not be given and intubation attempted with the patient breathing spontaneously.

• Open the mouth using the thumb and finger in scissor-like fashion between teeth.

• Insert the laryngoscope:

• Hold the laryngoscope in the left hand.

• Place it in the right side of the mouth.

• Sweep the tongue and laryngoscope toward the left.

• Place the tip of the laryngoscope in the vallecula or onto the epiglottis itself.

• Visualize the larynx by lifting the mandible with the laryngoscope blade toward the ceiling at a 45- to 60-degree angle to the child’s chest. Avoid “cranking” the laryngoscope back as if on a fulcrum, because this can cause injury to the lips and teeth.

• Visualize the cords, and then place the ETT in the right corner of the mouth beside the laryngoscope blade and advance the tube through the vocal cords. Avoid passing the tube down the laryngoscope itself, as that blocks the view of the larynx and straightens the tube, making it difficult to pass through the vocal cords.

• The tube should be advanced with the vocal cord mark just past the vocal cords to avoid right mainstem intubation.

After Procedure

Complications

• Esophageal intubation: quickly determined by lack of CO₂ detection, lack of chest wall movement, and lack of breath sounds

• Malposition of the ETT most commonly into the right mainstem bronchus; common in small infants owing to the short length of their trachea; detected by asymmetric chest rise and asymmetric breath sounds. If necessary, confirm position radiographically.

• Wrong size ETT, most commonly a too-small uncuffed tube, allowing for excessive air leak and inability to ventilate and oxygenate the patient; requires reintubation with proper tube size

• Undiagnosed difficult airway resulting in loss of airway during procedure or inability to place ETT; must be managed immediately either with laryngeal mask airway (LMA) or if necessary, cricothyroidotomy; may need fiberoptic bronchoscopy to visualize airway or may need creation of surgical airway

• Hemodynamic instability during procedure due to cardiovascular depressant effects of sedatives, hypoxemia during the procedure, or the patient’s underlying disease process. May need intravascular volume expansion or even chemical resuscitation if severe enough.

• Aspiration during intubation due to full stomach at time of intubation; risk is decreased if patient is placed nil per os (NPO) for at least 6 hours prior to intubation; however, aspiration is always a risk. Aspiration in patients known not to be NPO but who need urgent or emergent intubation is decreased with emptying the stomach with a large-bore nasogastric (NG) tube and with cricoid pressure maneuver during intubation.

• Patients with increased intraocular pressure may have worsening of the pressure, even resulting in extrusion of the vitreous, so rapid-sequence intubation as with increased ICP is recommended.

• Oral injuries are possible:

• Tooth injury or loss; check for loose teeth prior to intubation if time allows.

• Lacerations, bruising to lips and oropharynx

• Damage to tonsils, including avulsion

• Damage to vocal cords and laryngeal nerve, resulting in paralytic cord(s)

• Cervical spinal cord injury in patient with unstable cervical spine; risk is decreased when head and neck are immobilized at time of intubation.

Outcomes and Evidence

• Successful intubation in the pediatric patient depends on the length of training, level of supervision, ongoing experience of the practitioner, and the use of rapid-sequence intubation.

• Cuffed ETTs are as safe as uncuffed ETTs in the pediatric patient in a prospective data collection study in a pediatric intensive care unit (PICU).

• LMA can be successfully placed in pediatric patients but may be associated with increased risk of complications in younger patients:

• In a randomized controlled study of children 3 to 10 years of age in the operating room, both LMA and ETT were successfully placed on the first attempt in all patients, with less complications such as sore throat, coughing, vomiting, and hypoxia in the LMA group.

• Patients with multiple trauma and possible cervical spinal cord injuries who were intubated emergently had no further neurologic loss following intubation, according to a retrospective study of 237 injured patients; 21 patients (8.9%) had cervical cord or bone injury; 213 patients were orally intubated.

Intraosseous Infusion: Before Procedure

Indications

• Life-threatening situations when rapid intravascular access cannot be obtained

• Cardiopulmonary arrest

• Severe shock from all causes

• Status epilepticus

Contraindications

• Bone fracture

• Previous unsuccessful attempt at that site

• Infected or burned areas; relative contraindication

• Vascular compromise to the extremity

Anatomy

The preferable site for insertion is the anterior tibia, 1 to 2 cm below the tibial tuberosity on the medial aspect of the tibia. Other sites include the distal femur, medial malleolus, and anterior superior iliac spine. These sites are useful in pediatric patients from preterm neonates to adolescents. A sternal access system is now available for adult-sized patients.

Procedure

• Prepare site using sterile technique.

• Identify landmarks:

• Tibial tuberosity

• Flat part of the tibia 1 to 2 cm below the tuberosity

• Remove stylet and aspirate:

• If aspiration is successful, needle should be flushed.

• If aspiration is not successful, flush with 5 to 10 mL saline.

• If flushes easily, marrow has probably been entered.

• Attach connector tubing, and begin infusion.

After Procedure

Postprocedure Care

• Careful stabilization of the intraosseous needle

• Close observation for evidence of extravasation

Outcomes and Evidence

• Intraosseous infusion

• Easily and rapidly performed in emergency situations in both the prehospital and hospital environments

• Effective in delivering fluids, blood, and medications in emergency situations

• Safe, but attention to presence of infiltration or misplacement of the needle is important in preventing complications.

• Randomized control trial comparing standard bone marrow needle placement versus powered injector technique showed no significant difference with respect to success rate of placement, adverse events, and time to successful placement. Both techniques were successful about 80% of the time.

Central Venous Catheterization: Before Procedure

Indications

There are many indications for insertion of temporary central venous catheters (CVC) in pediatric patients, and often multiple indications coexist. Because there is risk associated with both insertion and maintenance of these catheters, it is imperative that a true indication for placement be met. If more than one indication exists, the risk/benefit ratio falls in favor of catheter placement.

• Monitoring of central venous pressure (CVP) and measurement of central venous oxygen saturation (ScvO₂) in hemodynamically compromised patients

• Poor peripheral venous access:

• Patients who need multiple IV access or long-term venous access

• Patients needing frequent phlebotomy

• Procedures:

• Continuous renal replacement therapy

• Hemodialysis

• Plasmapheresis

• Plasma exchange

Contraindications

All contraindications are relative, but the risks and benefits of the procedure must be weighed carefully.

• Coagulopathy:

• Correction of the coagulopathy should be attempted prior to procedure if the acuity of the situation allows.

• Sites with more risk in coagulopathic patients include subclavian and internal jugular veins; topical pressure to decrease bleeding is more effective at the femoral site.

• Skin infection at site of insertion

• Including diaper dermatitis for femoral vein catheterization

• Site-specific contraindications:

• Avoid femoral vein catheterization in patients with abdominal catastrophes, because patency of more central veins cannot be assured.

• Avoid internal jugular catheterization in patients with increased ICP.

• Patients with hyperinflated lungs are at increased risk of pneumothoraces with subclavian or internal jugular catheterization.

• Patients with active bacteremia are at risk for colonizing the CVC, so ideally the CVC would not be placed until blood cultures are negative. That is not always possible, depending on the acuity of the patient and the patient’s peripheral venous access.

Equipment

Proper insertion technique using full sterile barrier precautions and chlorhexidine prep of the skin have been shown to decrease infections associated with CVCs. Additionally, having the equipment including sterile gloves and drapes together in one location, such as a cart, increases the compliance with sterile technique by the insertion practitioner and makes insertion more efficient. A checklist of insertion practice also improves the compliance of proper technique.

• Sedation appropriate for age and condition of patient

• Local analgesia:

• 1% lidocaine with sterile syringe and narrow-gauge needle for infiltration

• Topical analgesia may be used prior to sterilely preparing the skin for adding analgesia.

• Sterile gloves, caps, masks, sterile drapes

• Skin preparation antiseptic:

• 2% chlorhexidine-alcohol based skin prep is recommended.

• Alternatives include 70% alcohol, tincture of iodine, iodophor.

• Steel hollow needles, guidewire, dilator appropriately sized for patient and catheter; kits containing the catheter, needles, guidewire, vessel dilator, and other equipment necessary for insertion are commercially available.

• Slip tip syringes

• Heparinized saline flush

• Tubing connectors

Anatomy

The selection of the site for insertion is based on the skill and experience of the operator and the patient’s condition and size. The femoral veins are relatively easy to access in nearly all pediatric patients. Although a risk with any site, bleeding is more easily controllable with femoral catheterization. As opposed to adults, the risk of femoral catheterization in infants and children does not appear to present a greater risk of infection than other sites. Use of the internal jugular vein is also relatively safe in most patients. The right internal jugular is associated with fewer complications than the left. Subclavian venous access is noted to have higher complications at the time of insertion, but the catheter is more easily secured and more comfortable for a mobile patient.

Access for the femoral vein in pediatric patients is similar to that in adults. The pulsations of the femoral artery are located below the inguinal ligament, and the vein is accessed medial to the artery about 1 cm below the inguinal ligament. If pulsations are not palpable, the site can be located halfway between the symphysis pubis and the anterior superior iliac spine. The right femoral vein is generally the preferred site because entry into the inferior vena cava is straighter, with the catheter less likely to enter other minor veins. For right-handed operators, there is more success of entry. Left-handed operators may choose the left femoral vein for easier access. The patient should be supine with legs positioned slightly frog-legged. Often a rolled towel or small blanket is needed underneath the buttocks to elevate and straighten the femoral vessels, allowing easier access.

For internal jugular access, the patient is placed supine in Trendelenburg position about 30 degrees head down if tolerated. The head is turned away from the side to be catheterized. The right side is preferable because of decreased complications and minimal manipulation to enter the superior vena cava. There are three techniques for entry to the internal jugular veins in children. Become proficient at one rather than attempting all three. The anterior approach is most common. First identify the carotid artery and the anterior border of the sternocleidomastoid muscle. The insertion site is at the midpoint of this anterior border. The needle should be introduced at a 30-degree angle and aimed at the ipsilateral nipple. The patient is placed in the same position for the subclavian approach, with the head turned away from the site of insertion. The suprasternal notch and the clavicle are identified. The needle is inserted below the lateral two-thirds of the clavicle and aimed at the suprasternal notch.

For subclavian access, a roll is placed between the shoulders and the patient positioned slightly in Trendelenburg position. The site of entry is just inferior to the lateral and middle junction of the clavicle. The needle is directed to the suprasternal notch and passes underneath the clavicle to enter the subclavian vein.

Procedure

The Seldinger technique is the most common for placing CVCs in infants and children. With ultrasound guidance, this technique is associated with decreased complications and decreased number of attempts in pediatric patients. In extreme circumstances, direct visualization of the vein by cutdown technique may be necessary.

• Seldinger technique:

• Wash hands and put on sterile gown and gloves.

• Sterilely prepare skin with 2% chlorhexidine scrub for at least 30 seconds, with at least 30 seconds of drying time for the chlorhexidine. For the groin, a 2-minute scrub with 30-second dry time is recommended.

• Sterilely drape the area using full barrier precautions.

• Numb the skin and underlying tissues.

• Pass the introducer needle into the vein, aspirating with a slip tip syringe.

• When venous blood enters the syringe easily, disconnect the syringe and pass the guidewire through the needle:

• The wire must pass easily and without resistance.

• The patient should be monitored for possible cardiac arrhythmias if the wire enters the heart and causes ectopy.

• Make a small incision at the site of the needle entry as large as the diameter of the vessel dilator.

• Remove the needle, taking care to keep the guidewire in position in the vessel, and then pass the vessel dilator over the guidewire to dilate the vein.

• Remove the vessel dilator, again taking care to leave the guidewire in place.

• Pass the catheter over the wire and into position; then remove the guidewire.

• Aspirate blood and any air from the catheter, and flush with heparinized saline; repeat for all ports.

• Secure the catheter with suture.

• Dress the catheter with the antiseptic-impregnated disc if desired, and then place the transparent dressing.

• Confirm position with a radiograph prior to using the catheter:

• For subclavian and internal jugular catheters: chest radiograph

• For femoral catheters: lateral abdominal radiograph to ensure catheter has entered the IVC

After Procedure

Postprocedure Care

Sterile insertion practices as already described and bundled maintenance care have been shown to significantly decrease the risk of CVC-associated bloodstream infections.

• Hand hygiene: prior to manipulating or accessing the CVC, proper hand hygiene should be performed to decrease the risk of transmission of pathogens.

• Wearing clean gloves is also recommended for accessing the CVC to further prevent transmission of pathogens but also protect the caregiver from contamination.

• Checklists and CVC kits:

• Providing a checklist of CVC maintenance procedures aids in reminding caregivers all the steps involved in CVC care.

• Kits of equipment needed for maintenance procedures, complete with all necessary materials and readily available in one place, aid in ensuring complete and appropriate performance of routine care.

• The catheter and catheter site must be assessed regularly:

• Daily assessment of the need of the catheter should be reviewed by the healthcare team, including nurses and physicians, and the catheter should be removed if the indications for placement no longer exist.

• The site should be examined for evidence of infection, such as redness at the site, drainage, swelling, or pain,

• The catheter should be examined for positioning, especially how much catheter is outside the skin and whether the securing maneuvers—suture or device—are still in place.

• Quality of dressing should be noted: whether it is still occlusive, presence of wetness under the dressing, and so forth.

• Dressing:

• Catheter site should be cleaned with antiseptic agent, preferably 2% chlorhexidine-alcohol combination.

• Chlorhexidine has not been labeled for patients younger than 2 months old; however, there is extensive literature and experience showing its safe use in infants as young as at birth.

• Povidone iodine may be used in patients with sensitivity to chlorhexidine.

• The use of iodine ointment is not recommended because of the increased risk of fungal overgrowth.

• Types of dressings:

• Transparent, semipermeable dressing: allows visualization of the site and does not have to be changed as frequently

• Gauze and tape: best used when the site is wet from blood, other fluid, or sweat; requires more frequent changes

• Flushing is performed for multiple reasons:

• Check patency of the line

• Clear the line of medications or blood products that may cause precipitation if in contact with other medications

• Clear the line with heparin-containing fluid to prevent thrombosis

• Lock the line or port that is not being used with concentrated heparin or antibiotic/heparin flush

• Routine replacement of the catheter is not recommended, especially rewiring the catheter, as this is associated with increased risk of infection. Because of limited venous access, routine rotation of CVC in children is not recommended.

Complications

Outcomes and Evidence

• Measurement of CVP allows calculation and maintenance of perfusion pressure (mean arterial pressure minus CVP), which provides better tissue perfusion in shock states.

• In a prospective randomized trial comparing pediatric patients with septic shock treated with and without ScvO₂ goal-directed therapy, patients treated with ScvO₂ goal-directed therapy had significantly less 28-day mortality (11.8% versus 39%) and less organ dysfunction than patients without.

• In a prospective study of planned transition in pediatric ICU patients from the landmark technique to the use of ultrasound guidance, use of ultrasound to guide placement of CVC was associated with decreased complications and fewer access attempts.

• In a multi-institutional, interrupted time-series design with historical control data in 29 PICUs, utilizing two CVC care practice bundles, an insertion bundle, and a maintenance bundle, the rate of catheter-associated bloodstream infections were decreased by 43% from 5.4 to 3.1 infections per 1000 central line days.

• To prevent catheter-associated thrombosis, preventive measures including routine flushing with heparinized saline, use of heparinized infusion fluids, and early treatment of possible occlusion with thrombolytics may decrease rates.

• A randomized control trial comparing heparinized fluid infusion to nonheparinized in infants with peripherally placed central lines showed significant decrease in thrombosis requiring catheter removal in the heparinized fluid group (6% versus 31%).

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