S32

S Afr Fam Pract
ISSN 2078-6190 EISSN 2078-6204

NWU REFRESHER COURSE

Introduction

The best way to perform a Rapid sequence induction (RSI) of
anaesthesia in the paediatric patient has been a longstanding
contentious issue amongst practicing anaesthetists. Paediatric
patients have many anatomical and physiological differences to
adults that make the performance of a classical RSI inappropriate
in these patients.

Over the last few years, the international literature has examined
the actual risk of peri-operative pulmonary aspiration in children
and found it to be much lower than previously thought.1-3
Studies have also shown that even once pulmonary aspiration
had occurred, the associated morbidity and mortality is not
significant.1-4

The reasons why children regurgitate and aspirate have recently
been assessed. There is good evidence to show that regurgitation,
vomiting and aspiration is caused by direct laryngoscopy
being performed while the patient is at an inadequate depth
of anaesthesia and muscle relaxation during induction and
intubation. These complications occurred with the classical
method of RSI and in some cases were directly associated with
the administration of cricoid pressure.4-6 Hypoxia, hypercarbia
and cardiovascular deterioration were all associated with the
performance of classical RSI in children.7-8

The steps involved in a classical RSI are no longer deemed
appropriate in paediatric anaesthetic practice for the following
reasons:

• Pre-oxygenation:

- It is often difficult to ensure adequate pre-oxygenation
of children because they are unco-operative and scared.
Cessation of spontaneous or assisted ventilation in infants
leads to rapid development of hypoxaemia (< 1 minute)
without pre-oxygenation. However, even if effective
pre-oxygenation is possible, time to desaturation is only
marginally prolonged.9 It is thought that the extra distress
caused by forcing the child to accept the mask for the few
minutes needed for pre-oxygenation is not worth the
marginal benefit conferred.

• IV access:
- Inhalational induction for neonates coming for pyloro-

myotomy is now a generally acceptable method of
induction negating the need for establishing IV access
pre-induction.11 IV access is not considered an absolute
must for induction of anaesthesia unless there is a concern
that the child may decompensate because of inadequate
resuscitation pre-operatively. Assessing the hydration
status of the patient (capillary refill time, static measures
of intra-vascular volume, heart rate, level of consciousness,
arterial or venous blood gas and input-output chart
over the last 12-24 hours) is a must to determine if the
child is adequately resuscitated. If not, IV access should
be established and a normal saline (N/S) fluid bolus of
20ml/kg administered pre-induction.

• IV induction agent:
- The use of a pre-determined dose of an IV induction agent

often leads to cardiovascular instability in children who
may not be successfully resuscitated prior to coming to
theatre for an emergency procedure. Careful titration of
hypnotic drugs is now advocated.

• Muscle relaxants:
- The use of suxamethonium in children is associated

with a number of deleterious effects including fatal
hyperkalaemic cardiac arrest, increasing intracranial
pressure and muscle pain.12 An appropriate dose of a non-
depolarising muscle relaxant is preferred.

• Cricoid pressure:
- The paediatric population have anatomical and

physiological differences that make managing the airway
more challenging than in adults. Cricoid pressure distorts
the fragile paediatric airway and increases the incidence
of difficult intubation in these already challenging
airway situations. Cricoid pressure has also been shown
to decrease the lower oesophageal sphincter tone and
cause bucking and straining in inadequately paralysed
patients.1,7 This all leads to increased risk of pulmonary
aspiration and cricoid pressure is no longer recommended
as a part of performing a RSI in children.

South African Family Practice 2016; 58(3):S32 -S35

Open Access article distributed under the terms of the
Creative Commons License [CC BY-NC-ND 4.0]
http://creativecommons.org/licenses/by-nc-nd/4.0

Rapid Sequence Induction of Anaesthesia in the Paediatric Patient:
Controversies and proposed protocol
MR Correia

Specialist Anaesthetist, Department of Anesthesia, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand
Corresponding author, email: drmichelle.correia@gmail.com

Rapid Sequence Induction of Anaesthesia in the Paediatric Patient: Controversies and proposed protocol 33

S33

• Time to intubation and the apnoeic period:

- The apnoea tolerance in children is reduced to such
an extent that even short periods of apnoea cause
rapid desaturation, hypoxia, hypercapnia and possible
cardiovascular deterioration.7-9,13 Waiting for the “magical
minute” to secure the airway without bag mask ventilation
as described with the classical RSI in adults, has been shown
to be associated with severe complications9. Gentle bag
mask ventilation and inflation of the lungs to pressures not
greater than 12cmH2O have shown to prevent hypoxia and
hypercarbia and allows time to achieve adequate muscle
relaxation. This actually decreases the risk of coughing,
straining and subsequent aspiration at intubation.5,9

• Type of endotracheal tube

- The use of cuffed endotracheal tubes (ETT) in paediatrics
is also cause for debate.14 Theoretically, there are a
number of advantages to using a cuffed ETT including
definitive airway protection, better ventilation and
oxygenation, more precise monitoring of end tidal carbon
dioxide intra-operatively and decreased consumption of
volatile anaesthetic agents. However, cuffed ETTs seem
to be different between suppliers making the size and
positioning of the cuff on the ETT unreliable. This can lead
to several problems including excessive pressure from
the cuff being transmitted to the glottis, cuff herniation
through the vocal cords compromising ventilation and
damage to the tracheal mucosa from excessive inflation.
All of these factors may lead to subglottic stenosis which
may be difficult to treat and add significantly to the
patient’s overall morbidity and mortality. The make and
type of cuffed ETT is therefore an important consideration
and should be checked before being used.

Because of the above evidence, specialist paediatric units
internationally have changed practice to doing a “controlled”
RSI and intubation (cRSII) for their patients. After an extensive
literature search, the following are key points involved in a
cRSII:7,13

• Sufficient depth of anaesthesia and adequate muscle
relaxation must be achieved before direct laryngoscopy and
intubation are performed so as to limit the risk of aspiration
and airway trauma.

• Maintenance of depth of anaesthesia can be done via titration
of IV agents or inhalational agents administered during gentle
bag mask ventilation.

• Prevention of hypoxia and hypercarbia is paramount and
achieved via gentle bag mask ventilation with pressures less
than 12cmH2O.

• Cricoid pressure is not appropriate in the paediatric patient.

• An appropriately manufactured and sized cuffed ETT should
be used to secure the patient’s airway if available.

Protocol

Pre-operatively:

Patient assessed as being at risk for regurgitation of gastric
contents and possible pulmonary aspiration:

Indications:

• NPO < 4 hours for solids, breast milk or formula

• NPO < 2 hours for clear fluids

• Any gastro-intestinal obstruction

• Delay of gastro-intestinal passage:
- Ileus
- Peritonitis
- Renal insufficiency
- Diabetes mellitus
- Acute trauma
- Severe pain

General condition of child:

• Happy, playful, active, good interaction, well-looking

• Miserable, lethargic, ill-looking

• Vital signs:
- Check HR, NIBP, SpO2, temperature, HGT, blood results

from ward chart
- Address any abnormalities with appropriate standard of

care (e.g.: order blood products, take into account any
organ dysfunction in the selection of anaesthesia drugs)

Volume status assessment:

• Check that the child is fully resuscitated pre-induction
- Volume status assessment

> Static measures:

» NIBP

» Urine output

» Skin turgor, sunken eyes, sunken fontanelle

» Blood results: urea, haematocrit, sodium

> Dynamic measures:

» Heart rate

» Level of consciousness

» Capillary refill time

» Arterial or venous blood gas

* SvO2 (central venous saturation)

* Lactate

* Severity of metabolic acidosis
- If child assessed as being under-resuscitated and fluid

responsive, IV access must be established awake and a
fluid bolus given: 20ml/kg bolus N/S (or colloid: Voluven or
appropriate blood products) and check response. If there
is a positive response to the fluid challenge, reassess the
above parameters and decide if another fluid challenge
is indicated. Weigh up the risks of proceeding with the
induction vs the expected benefit of time taken for
extra resuscitation. Discuss with the surgeon to develop
management plan.

• Assess the electrolytes – is there a need for correction? Weigh
up the risk of the electrolyte disturbance against the benefit
of performing emergency surgery. Approach ICU for post-
operative support if required.

• Degree of abdominal distention: try to localise the cause of the
GIT obstruction (upper, middle or lower GIT) or other causes
such as solid organomegaly. Severe abdominal distention

S Afr Fam Pract 2016;58(3):S32-S3534

S34

increases the risk of regurgitation and interferes with
pulmonary mechanics which causes ventilation problems.
A head-up position during induction helps to displace the
abdominal contents away from the diaphragm which may
improve ventilation during pre-oxygenation and induction.

Nasogastric tube:

• In patients with GIT obstruction, a naso- or oro-gastric tube
(NGT) that is placed correctly and draining well must be in situ
prior to induction of anaesthesia.

• The NGT must be suctioned with the patient in various
positions. The gastric volume and pressure should be reduced
as much as possible prior to induction.

Pre-medication:

• Midazolam for anxiolysis and opioids for pain control can be
slowly titrated to effect.

• Caution must be used especially if the child appears clinically
under-resuscitated.

• Pro-kinetics and agents that reduce gastric pH and volume
can be used but are not routinely recommended especially in
the setting of GIT obstruction.

Equipment check:

• Large bore Yankuer or soft suction catheter with strong
suction vacuum must be readily available, switched on and
placed at the patient’s head.

• Age and weight appropriate intubation equipment

- Laryngoscope handle with bright light in good working
condition

- Different size Miller and Macintosh laryngoscope blades

- Malleable introducer or intubating stylet

- Magill’s forceps

- Humidification filter on circuit

- Cuffed ETTs

> Equation for patient’s older than 1 year: Age/4 + 3.5

> Have a 0.5mm internal diameter smaller size ETT
available

> If no appropriately sized cuffed ETT is available, use an
uncuffed ETT

- Make sure the operating table is functional and can be
quickly placed in the head down position if required.

- Ensure that your anaesthetic machine is checked and that
the APL valve is in good working condition.

- Have a Jackson-Reese circuit available if the child is < 20kg.

- Set ventilator pressure support mode with pressures
limited to < 12cmH2O for gentle bag mask ventilation
during induction.

Patient preparation:

• Check IV line is running well.

• Continue to treat pain and anxiety if appropriate with small
doses of midazolam and opioids.

• If a NGT is in situ, place on continuous suction and leave in
situ.

• Establish standard ASA monitoring
- 3 lead ECG
- Non-invasive Blood Pressure (NIBP)
- SpO2

• A neuromuscular transmission (NMT) monitor should be used
if available to ensure adequate muscle relaxation prior to
intubation.

• If the patient is older than 2 years of age, place in a 20° head-
up or Anti-Trendelenburg position.

• Pre-oxygenate with 100% O2 and a tight fitting mask if
possible
- Institute oxygen analysis and ETCO2 monitoring

Induction:

Opioids such as fentanyl 1-3mics/kg or sufentanil 0.1-0.3mics/kg
can be titrated in slowly prior to induction.

For patients in cardiovascular shock:

• Induction agent
- Ketamine 2mg/kg
- Etomidate 0.3mg/kg

• Muscle relaxant
- Suxamethonium 1-2mg/kg
- Atracurium 1mg/kg
- Cisatracurium 0.15mg/kg
- Rocuronium 1mg/kg (for longer procedures and post-op

ventilation)

For neonates and infants < 3 months who are haemodynamically
stable:

• Induction agent
- Propofol 4-5mg/kg titrated in slowly

• Muscle relaxant
- Atracurium 1mg/kg
- Cisatracurium 0.15mg/kg

For infants and children > 3 months who are haemodynamically
stable:

• Induction agent
- Propofol 3-4mg/kg titrated in slowly

• Muscle relaxant
- Atracurium 1mg/kg
- Cisatracurium 0.15mg/kg

NO CRICOID PRESSURE

Ventilation via facemask:

• Gentle bag mask or ventilator driven (on pressure support
mode) ventilation is performed to prevent the rapid
desaturation and hypoxia associated with apnoea in children
- Peak inspiratory pressures (PIP) must not exceed 12cmH2O

• High frequency, low pressure and low volume hand ventilation
with a Jackson-Reese circuit may also be used to prevent the
development of hypoxia.

• Once supported ventilation is established, administer non-
depolarising muscle relaxant.

• Start train of four (TOF) monitoring on NMT if available.

Rapid Sequence Induction of Anaesthesia in the Paediatric Patient: Controversies and proposed protocol 35

S35

• Sevoflurane 1-2% or supplemental doses of hyponotic drugs
(e.g. propofol 0.5mg/kg every 15-45s) must be administered
during this time to maintain depth of anaesthesia.

• Continue to monitor vitals (HR, SpO2, NIBP on 1 minute cycle
time) and gas analysis (oxygen and agent analysis, ETCO2
monitoring).

Intubation:

• Once ‘zero single twitch’ is established or adequate time
for muscle relaxant to take effect has passed (1-3 minutes
depending on which drug and dose is used), intubation can
be performed.

• Gentle external laryngeal pressure with a BURP (backward,
upward and rightward pressure) manoeuvre may be done by
an experienced assistant to facilitate intubation.

• Confirm adequate ventilation (tidal volumes) and ETCO2 .

• Confirm correct ETT placement clinically and secure the ETT
at the appropriate level.

• Check cuff pressure with a manometer if available (keep cuff
pressures 20-25cmH2O)
- If no manometer available, deflate the cuff gently and

increase PIP to 20cmH2O – you should have a leak around
the ETT

- Inflate the cuff with 0.5-1ml of air gently until the leak is no
longer audible at PIP of 20cmH2O

- If no leak is audible and ventilation is adequate without
cuff inflation, do not inflate the cuff

• Remember to check ETT position and adequacy of ventilation
after any re-positioning of the patient during the procedure.

Emergence:

• Muscle relaxant should be fully reversed
- Monitor with NMT if available

• Suctioning of a large bore NGT should be performed prior to
extubation.

• Adequate suctioning of oro-pharynx must be performed.

• Extubate patient fully awake.

• Assess for adequate airway maintenance post-extubation
- Good air movement felt and heard around nose and mouth

- Normal movement of chest wall with no signs of obstruc-
tion

• Monitor for and rule out post-extubation airway or respiratory
complications post-op in recovery:
- Post-extubation stridor
- Upper airway obstruction from residual effects of anaes-

thetic drugs
- Inadequate respiratory effort from residual neuromuscular

blockade leading to hypoxia and hypercarbia

References

1. Kelly CJ, Walker RW. Perioperative pulmonary aspiration is infrequent and low
risk in paediatric anaesthetic practice. Pediatric Anesthesia 2015; 25: 36-43.

2. Walker RW. Pulmonary aspiration in paediatric anaesthesia practice in the United
Kingdom: a prospective survey of specialist paediatric centres over a one year
period. Paediatric Anaesthesia 2013; 23: 702-11

3. Warner MA. Perioperative pulmonary aspiration in infants and children.
Anesthesiol 1999; 90: 66-71.

4. Warner MA, Warner ME, Webber JG. Clinical significance of pulmonary aspiration
during the peri-operative period. Anesthesiol 1993; 78: 56-62

5. Kalinowski CPH, Kirsch JR. Strategies for prophylaxis and treatment for
aspiration. Best Pract Res Clin Anaesthesiol 2004; 18: 718-737

6. Kluger MT, Shor TG. Aspiration during anaesthesia: review of 133 cases from the
Australian anesthetic incident monitoring study (AIMS). Anaesthesia 1999; 54:
19-26

7. Engelhardt T. Rapid sequence induction has no use in pediatric anesthesia.
Pediatric Anesthesia 2015; 25: 5-8.

8. Gencorelli FJ, Fields RG. Complications during rapid sequence induction of
general anesthesia in children: a benchmark study. Pediatric Anesthesia 2010;
20: 421-424.

9. Patel R, Lenczyk M, Hannallah RS. Age and the onset of desaturation in apnoeic
children. Can J Anaesth 1994; 41: 771-4.

10. Spencer AO, Walker AM. Ultrasound assessment of gastric volume in fasted
pediatric patients undergoing upper gastrointestinal endoscopy: development
of a predictive model using endoscopically suctioned volumes. Pediatric
Anesthesia 2014; 25: 301-308.

11. Scrimgeour GE, Leather NW. Gas induction for pyloromyotomy. Pediatric
Anesthesia 2015; On-line publication 23 February

12. Rawicz M, Brandom B, Wolf A. The place of suxamethonium in pediatric
anesthesia. Pediatric Anesthesia 2009; 19: 561-570

13. Neuhaus D, Schmitz A. Controlled rapid sequence induction and intubation – an
analysis of 1001 children. Pediatric Anesthesia 2013; 23: 734-740.

14. Tobias JD. Pediatric airway anatomy may not be what we thought: implications
for clinical practice and the use of cuffed endotracheal tubes. Pediatric
Anesthesia 2015; 25: 9-19