Ages for paralysis
Started by ethilo
I'm a PICU attending and I'd argue that using paralytic for all children would represent the standard of care in my field with the standard sort of exclusions based on pathology and associated risks. I don't attend deliveries any more but the delivery room is about the only place where I'd routinely attempt without paralytic, especially because so many intubations in the DR now are for surfactant admin only and then you pull the tube pretty quick thereafter. There has been a sea change among neonatologists in just the last 10 years about even giving preemies sedation for intubation - used to never give anything, but between my intern year and my 3rd year of residency the practice completely changed. Very distinct memories of my senior resident telling me to wait for in between screams to slide the ETT in for a surfactant dose.
Now granted, y'all are in the OR, have a variety of different options for getting kids down, so you could make the argument there are situations where it's less of a need given the deeper plane of anesthesia.
I do not routinely use atropine as a part of my standard intubation cocktail. All cases I've had were triggered by vagal stim from the DL and so gets better when you remove your blade. If it happens, then go ahead and give the atropine, but not needed as pretreatment.
There are many pediatric intensivists, myself included, who were trained to consider sux an extremely rare choice for paralytic in children. We most often are intubating younger children, whose medical conditions may include as yet uncovered genetic diseases and myopathies - things that won't present themselves for years. While it's an extremely small chance we might uncover a muscular dystrophy patient, there are reasonable alternatives that are safer, so the teaching is frequently that it's an unnecessary risk. Again, in the right patient population, the shorter duration of effect from sux might be warranted and worth the risk. If nothing else, I'm not typically in the business of intubating someone and then trying to take the tube out 45 minutes later - the disease processes that lead to my tubes tend to last a while longer, so the longer duration of paralysis matters less for me. Meanwhile y'all are making choices that affect how well you can accomplish other tasks in the very near term future.
Now granted, y'all are in the OR, have a variety of different options for getting kids down, so you could make the argument there are situations where it's less of a need given the deeper plane of anesthesia.
I do not routinely use atropine as a part of my standard intubation cocktail. All cases I've had were triggered by vagal stim from the DL and so gets better when you remove your blade. If it happens, then go ahead and give the atropine, but not needed as pretreatment.
There are many pediatric intensivists, myself included, who were trained to consider sux an extremely rare choice for paralytic in children. We most often are intubating younger children, whose medical conditions may include as yet uncovered genetic diseases and myopathies - things that won't present themselves for years. While it's an extremely small chance we might uncover a muscular dystrophy patient, there are reasonable alternatives that are safer, so the teaching is frequently that it's an unnecessary risk. Again, in the right patient population, the shorter duration of effect from sux might be warranted and worth the risk. If nothing else, I'm not typically in the business of intubating someone and then trying to take the tube out 45 minutes later - the disease processes that lead to my tubes tend to last a while longer, so the longer duration of paralysis matters less for me. Meanwhile y'all are making choices that affect how well you can accomplish other tasks in the very near term future.
Advertisement - Members don't see this ad
D
deleted87051
Completely different setting. Many kids in the OR are intubated for very short ENT procedures. Sevoflurane+-propofol is routine and all it takes.
Which is why I qualified my answers.
What does age have to do with it? We will paralyze a 0 day old volvulus. Shouldn't the procedure matter more than the age? I've seen brady from Sux maybe twice in 6 years of peds. Atropine is +/-. I think a lot of older attendings give it out of habit, but I don't think it's a necessity.
Agree mostly with this.
I haven’t given sux to a Pediatric pt in over 10yrs and that is being conservative. I was trained not to use it at all after a certain age, I think think that was maybe 2yrs. I have pushed it down even further to 6months. If I need rapid elaxation then I give it early. It it’s a kid and they are easy to intubate without relaxants so I don’t worry about it. I’d rather have a slightly limited view than a cardiac arrest.
I also, have never given atropine to a kid outside of a code. I do use glyco liberally though. I like the drying effect as much as the increased HR. I do a lot of deep extubations with kids and I want them dry.
