Factors Associated with the Underuse of Sedatives and Neuromuscular Blocking Agents for Pediatric Emergency Endotracheal Intubation in Korea

Abstract

Purpose Rapid sequence intubation (RSI) using sedatives and neuromuscular blocking agents (NMBAs) is recommended for pediatric emergency endotracheal intubation (ETI), but is not frequently performed in Korea. This study aimed to verify factors associated with the underuse of RSI medications. Materials and Methods This multicenter retrospective study reviewed patients aged under 18 years who underwent an ETI within 24 hours of arrival at the emergency department between 2016 and 2019. Any cases of ETI during cardiopulmonary resuscitation were excluded. We investigated the characteristics of the patients, intubators, RSI medications, and outcomes. The study cases were classified into no-medication, sedative-only, and sedative-with-NMBA groups. Multivariable logistic regression analysis of RSI medication use was conducted. Results A total of 334 cases with a median age of 3.4 years were included in this study. Sedatives and NMBAs were used in 63.8% and 32.9%, respectively. In comparing the no-medication (n=121), sedative-only (n=103), and sedative-with-NMBA (n=110) groups, patient age (median; 1.0 year vs. 2.8 years vs. 11.3 years; p <0.001), underlying medical conditions (77.7% vs. 56.3% vs. 36.4%; p <0.001), and pediatricians as intubators (76.9% vs. 54.4% vs. 17.3%; p <0.001) were different. The factors that influenced sedatives with NMBA use were patient age [for a year increment; adjusted odds ratio (aOR), 1.182; 95% confidence interval (CI), 1.120–1.249], no underlying medical conditions (aOR, 2.109; 95% CI, 1.093–4.070), and intubators other than pediatricians (aOR, 5.123; 95% CI, 2.257–11.626). Conclusion RSI accounted for 32.9% of pediatric emergency ETI in Korea. The underuse of RSI medications is associated with younger patient age, underlying medical conditions, and pediatricians as intubators.

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“…One of the attempts to prevent hypoxia in RSI is apneic oxygenation, consisting of providing oxygen to the patient in apnea during laryngoscopy and insertion of the orotracheal tube. In our review, the study found by Overmann et al 12 did not indicate benefits from this approach. However, a specific integrative review on the topic, published in 2019, indicated that there may be benefit to this procedure, although there is no strong evidence in the literature.…”

“…Although the use of medications during and after RSI is well established in the literature, this review identified that many professionals who work in pediatric emergencies still do not correctly indicate medications. Lee et al 12 reported that, in younger patients or those with comorbidities, there is a greater probability of insufficient use of medications during the procedure. This is possibly due to an excessive fear of side effects, which is not justified in the literature.…”

“…When comparing RSI with intubation without the use of neuromuscular blockade, the latter had a considerably lower success rate (55%) compared to the former (83%) 3 . Furthermore, when the doctors performing the intubation were pediatricians, they were more likely to use medications inappropriately compared to other professionals 12 , which could perhaps be explained by a lack of studies and updates on the topic.…”