Risk factors for inadequate sedation after endotracheal intubation in the pediatric emergency department

Introduction

Rapid sequence intubation (RSI) is performed for the majority of children undergoing emergency endotracheal intubation in pediatric emergency departments (PED) or pediatric intensive care units (PICU) [ 1 , 2 ]. RSI is defined as administration of a sedative and paralytic in rapid succession to facilitate efficient tracheal intubation [ 1 , 3 ]. After RSI, additional sedation is typically necessary to avoid patient harm and discomfort [ 456 ].

Inadequate post-intubation sedation has been reported in as many as one-third of adult patients in critical care settings [ 5 ]. Further, awareness of paralysis has been recently been reported in 2.6% of intubated adult ED patients [ 6 ]. Patients with awareness from inadequate sedation after paralysis and intubation describe feelings of fear, violation, loss of control, or even imminent death [ 4 ]. Inadequate sedation also potentially increases the risk of unplanned extubation and hypoxemia with its downstream adverse effects [ 7 ]. In addition, assessing the depth of sedation for a paralyzed patient after RSI is difficult. Without visible breathing and other movements, the available indicators of patient distress are indirect and limited, including tachycardia and hypertension.

There are two published studies of post-intubation sedation in pediatric patients, both reporting inadequate post-intubation sedation in more than three-quarters of patients [ 8 , 9 ]. Kendrick et al. focused on RSI with etomidate and a long-acting paralytic, and did not explore risk factors for inadequate sedation [ 8 ]. Berg et al. reported three risk factors for inadequate sedation: the use of a long-acting paralytic, lower systolic blood pressure, and admission to the pediatric intensive care unit [ 9 ]. There are no studies of post-intubation sedation performed in the setting of a standardized RSI process. Standardization, in particular with a procedural checklist, has been reported to improve the safety of RSI [ 10111213 ].

Since 2012, our academic PED utilized a standardized, checklist-based protocol for RSI and modified RSI performed in the department. We reported our RSI protocol resulted in improved performance, safety, and timing of medication administration [ 11 , 14 ]. The objective of this current work is to determine the proportion of pediatric patients who experience inadequate sedation after RSI, despite use of our standardized RSI protocol which prompts providers to remember post intubation sedation. We also sought to identify risk factors for inadequate sedation in those patients who experienced a delay.