The purpose of this video is to provide general information and education about the care of
a critically ill child.
It is in no way a substitute for the independent decision making and judgment by a qualified
health care professional.
The information contained in this video should not be used to make a diagnosis or to overrule
the advice of a qualified health care provider, nor should it be used to provide advice for
emergency medical treatment.
Sedatives and Analgesics for Intubation, by Doctor Robert Pascucci.
Please note that, in this video, we will be following the guidelines used at Boston Children's
Hospital.
Some of this information may need to be modified based on the equipment, guidelines, and practices
in place in your institution.
Hi, I'm Bob Pascucci.
I'm one of the ICU staff here at Children's Hospital Boston.
What we're going to talk about today is the drugs that you might consider using in a semi-urgent
intubation in the ICU setting.
And I'll give you a sampling of the drugs that we use here.
Some of them may or may not be available to you immediately where you are practicing,
but most of them are pretty commonly available.
And for the most part, they're older drugs that aren't really brand new.
Introduction.
Let's go on to the main courses.
We'll talk about those.
Some of those things can be used in smaller doses as appetizers.
And we'll come back to those as we go on.
Remember that what we're really trying to do here is generate a short general anesthetic.
And that means that you need something for sedation or hypnosis, something to put the
patient to sleep.
You need something for amnesia because you don't want the patient to remember what happened.
You need something for analgesia, meaning you're trying to take away the pain associated
with the laryngoscopy and intubation.
And then, finally, you need muscle relaxation to help the child hold still during the procedure.
And different combinations of drugs will give you different things.
As we go through the drugs, I'll try to point out what does what.
And then you sort of make up a package that seems to work for the clinical setting that
you're in.
And it really is the clinical setting that determines what you want to do because the
drugs have different advantages and disadvantages depending on where you're using them.
Thiopental.
Point of Clarification: Thiopental has not been available for use in the United States
since around 2011.
Let's go over to the middle column here, the main courses, and start at the top.
Thiopentol, the brand name in the United States, is Pentothol, but there may be different brand
names elsewhere.
It's a barbiturate, it's a tried and true drug class, it's familiar to most people,
and it's very similar to phenobarbital or pentobarbital or any of the other barbituates
that you might consider using.
The difference with Pentothol between this and, say, phenobarbital is time of onset,
60 to 90 seconds, so it's fairly quick; and time of offset, five or 10 minutes.
So the timing is different with Pentathol or with thiopental.
And the other thing is the primary effect.
The primary effect of phenobarb, for example, would be to control seizures and oh, by the
way, the patient might get sleepy.
Here, the primary effect is to put the patient to sleep and if the patient happens to be
seizing you'll probably control those as well.
So when would you want to use Pentothal specifically?
It's particularly good in one circumstance.
It's good to control increased intracranial pressure, ICP.
And it's particularly bad for hemodynamics.
And as long as you remember that, I think you'll use Pentathol properly.
If I have some child who has increased intracranial pressure, or suspected increased intracranial
pressure-- for example, a head trauma patient that comes into the emergency room or someone
who has a brain tumor or that sort of setting-- then I might specifically want to use a drug
that's going to control the ICP as I put the endotracheal tube in.
And in my book, Thiopental is probably the best drug to use for that.
It's bad for hemodynamics, and if you have someone who's marginal in terms of blood pressure,
marginal in terms of profusion, pentothal will make that worse.
So that I think it's good for ICP, bad for human dynamics.
Remember those two things.
If you have somebody who has increased ICP but their hemodynamics are bad, it would be
a mistake to use Pentathol because really the hemodynamics take precedence over the
ICP control.
Now, the doses I have written here, two to four milligrams per kilogram, are averages
and you really have to adjust those to the patient.
If I have a very athletic patient, for example, who happens to have a fracture and needs to
go to sleep for that, I might be giving four or six milligrams per kilogram of Pentathol
to get them to sleep.
If it's an older woman with a broken hip, one per kilo might be enough to put her to
sleep and perhaps even make her apnec.
So you really have to adjust the dose of Thiopental depending on the circumstances that you're
using it for.
It is just a go to sleep drug, it really doesn't provide any amnesia and doesn't provide any
analgesia.
Just to know that.
So that's Pentathol.
Ketamine.
Ketamine, the next drug on the list, is used in a variety of clinical settings-- in sedation
in the emergency room, for example.
Analgesia, anesthesia for short procedures.
What I'm going to do is limit the discussion here just to its use in intubation.
And when would you consider using ketamine for an intubation?
It's almost in some ways the opposite of thiopentol.
It is not particularly good for ICP, it's good for hemodynamics, and it's good for asthma
or reactive airway disease, OK?
Now, the not particularly good for ICP part is pretty simple.
People used to think that ketamine actually made intracranial pressure go up.
I think more recent data suggests that that doesn't necessarily happen as long as you
control ventilation, but it isn't particularly beneficial for intracranial pressure control,
either.
So if you have somebody with increased ICP, I would probably avoid Ketamine.
If you have somebody who's hemodynamics are marginal, Ketamine is a good drug because
if you administer ketamine to someone, you get an outpouring of endogenous catecholamine.
So epinephrine and norepinephrine released from stores tend to go up in the bloodstream,
tend to cause some vasoconstriction, and therefore maintain the blood pressure.
So if you have someone, for example, who's hypovolemic, someone who's lost blood volume,
and they need to go to the operating room right now or they need to be intubated right
now, ketamine is a drug that you would consider using because it will not make the patient
hypotensive.
It may even make the patient hypertensive if they have a normal volemic status, and
usually that's pretty well tolerated and it goes away.
So it's good for hemodynamics.
It's also good for reactive airway disease for asthmatic kids because ketamine tends
to be a bronchodilator.
And if you give ketamine alone, you can actually use it as a bronchodilator or as a sedative
in some intubated child with asthma.
But particularly if you're going to intubate somebody with asthma, we like to use ketamine
because it will tend to minimize the reactivity that they have when the endotracheal tube
is finally in place.
So not particularly good for ICP, good for hemodynamics, good for asthma or reactive
airway disease.
Dosing, one to three per kilo.
Again, these are average doses.
If I were going to intubate someone and use ketamine alone-- which is uncommon, but you
could do that-- I would probably give two to three milligrams per kilogram.
You can give the drug intramuscularly, IM, so that if for some reason you lost your IV
or you were really in an urgent sort of setting when you needed to give a drug IM, you could
use ketamine and it would work intramuscularly.
In those cases, I would tend to give three or even four milligrams per kilogram as a
higher dose just to make sure that it gets absorbed.
Now, ketamine is one of the drugs on the list the does many things.
It's an amnestic because you really don't remember what's happened after you've gotten
ketamine; it's a sedative in the sense that it's a dissociative agent so that even though
the patient doesn't look like they go to sleep, often they get nystagmus and they don't really
seem to be asleep in the classic sense, they really don't remember what's happening; and
it's an analgetic so that it's good for pain, it does give some pain relief.
So that sort of puts it in a little bit of a different category and tends to do more
than just put you to sleep, it does a variety of other things that you're trying to do at
the same time.
So it's a nice drug from that point of view.
The downside of ketamine is that you can get some dysphoric or unpleasant side effects.
And people who have had ketamine for procedures sometimes will describe bad dreams or unpleasant
sort of imagery.
And you can usually get around that by adding some Midazolam.
And we'll talk about that in a minute.
But often, giving some Medazolam before you give the ketamine is a good idea.
The other thing it will tend to do is increase secretions, it is a sialogogue, so that increased
secretions might be an issue in terms of intubation.
And again, if you've given by glycopyrrolate or atropine ahead of time, you can usually
block that effect of ketamine and you might want to consider doing that, particularly
if you're going to use ketamine.
All right.
So that's ketamine.
Benzodiazedpines and Narcotics.
Now, the next drugs are really combination.
And I'm saying the midazolam and fentanyl, but it could be almost any benzodiazepine
and almost any narcotic.
These two happen to be relatively fast-acting, short-duration.
And for a short-term procedure like intubation, that's probably what you want.
You can give full doses-- 0.1 milligrams per kilogram, or fentanyl is micrograms, so it's
2 to 4 micrograms per kilogram-- and use those as its full doses.
Or you can do what I frequently do is make these appetizers instead of main courses so
that you give half doses.
You get a small amount of midazolam, a small amount of fentanyl while you're getting ready.
So, if little Johnny is getting ready to be intubated, and he doesn't particularly-- you
know, he's awake, he doesn't particularly like the procedure, you can give him a little
bit of midazolam, maybe 0.05 milligrams per kilogram, get a little mask on his face, have
him breathe some oxygen-- geez, Johnny, you're doing very well-- and give him a little bit
of fentanyl, maybe another microgram per kilo instead of 2.
And you can do this sequentially so that you give a dose of midazolam, a dose of fentanyl,
a dose of midazolam, a dose of fentanyl.
Monitor the child's breathing.
Monitor the child's blood pressure.
Get them nicely sedated without really losing protective reflexes, without losing blood
pressure, without losing any sort of compensatory response that they've been generating, and
just stopping when you think that you've got the result that you want.
And then going ahead with the other drugs to put them to sleep and put the tube in.
And that way, you've gotten some amnesia and some sedation from the midazolam, you've gotten
some analgesia from the fentanyl, and that's a nice combination.
You can also see what the child looks like before you really put them to sleep, so that
you'll know that, well, this is how comfortable the child is.
So, if I put the endotracheal tube in, and if I have to put in an arterial line or a
central line or something like that after the tube is in, I'll know that I've at least
got this level of sedation and analgesia, and that it's going to last for typically
a half an hour or 45 minutes.
So I like to use midazolam and fentanyl as appetizers, as premedications for almost anything
that I do, almost any procedure in the ICU.
All right, so that's those drugs.
Propofol.
Propofol is a newer agent and it's quite useful.
It's very similar to Pentothal, in the sense that the time and course is the same.
Onset time is about 60 seconds.
Offset time is about 5 or 10 minutes.
It has the same profile.
It's good for ICP, and it's bad for hemodynamics in its similar fashion.
I personally think that thiopental is a little bit better then Propofol in terms of controlling
the ICP, but people could certainly argue with that.
What's the advantage of Propofol?
It's really very simple.
If I put you sleep with thiopental, you're going to go to sleep.
You're going to wake up in 5 or 10 minutes and you're going to feel very groggy, unpleasant.
If I put you sleep with Propofol, you're going to go to sleep, you're going to wake up in
5 or 10 minutes and you're going to feel great.
And that is really the difference.
You wake up much more clear headed from Propofol then you do from almost any of the other drugs
on the list.
Now, why would I want that?
Well, in day surgery settings or in operating room settings, it's a very nice drug to have
because people can have outpatient surgery with Propofol wake up, feel great, go home.
And it's a little bit of an antiemetic, which is a plus.
In the ICU setting, that may not be so important.
But it is important to have someone who you can judge the mental status of.
So if someone is a little bit off, not quite with it in terms of mental status but you
have to put them to sleep for procedure and you want them to wake up so that you can evaluate
their mental status again, Propofol is probably the right drug to use for that.
You do have to be careful about blood pressure because it is a hemodynamic suppressant just
like Pentothal is.
So that's Propofol.
Etomidate.
And, finally, etomidate is on the list.
And that tends to be the most hemodynamically protective of all the drugs on the list.
If you have someone who really is in marginal condition hemodynamically, you're in kind
of a rush to get the tube in, 0.2, 0.3 milligrams per kilogram of etomidate is a safe way to
induce someone.
And I think that most people in an ICU practice would feel comfortable using etomidate to
intubate someone who is hemodynamically unstable, because, of all the drugs on the list, it
is going to maintain hemodynamic stability the best.
There are some caveats to using etomidate.
The first is that you can create some clonic activity when you administer the drug.
So, if there are random arm or extremity motions, it's just a side effect of the drug, and it's
not a serious one.
More importantly, though, you can get adrenal suppression from the use of etomidate.
It doesn't seem to be clinically significant with just one dose of etomidate, but it can
be, and certainly multiple doses of etomidate over a period of time can cause clinical adrenal
suppression.
Our practice at Children's Hospital in Boston is that we will use etomidate for somebody
who is hemodynamically unstable, because we think that, in the moment of intubation, it
is the safest drug to use.
But we are quite aware of the fact that we may be causing adrenal suppression, and we
watch the patients carefully for that and supply stress-dose steroids as soon as we
think that they are clinically indicated.
Some people will even give stress-dose steroids if they have given etomidate just to make
sure that doesn't become an issue.
Point of clarification.
Please note that the American College of Critical Care Medicine 2007 update now states that
etomidate is not recommended for children with septic shock unless it is used in a randomized
controlled trial format.
Lidocaine.
I put lidocaine on here.
Lidocaine is sort of an adjunct, a condiment to all these things.
And it's particularly good for two things.
One is control of ICP and two is wheezing or reactive airways disease.
The ICP one is fairly straightforward.
If I use lidocaine as sort of a supplement to these things, I can probably get a little
bit less of a spike in intracranial pressure with my intubation than I would if I hadn't
used lidocaine.
So it's a little bit protective in terms of controlling intracranial pressure when you
put an endotracheal tube in.
Similarly, with reactive airways disease, many people feel that lidocaine is good in
terms of suppressing reactivity in airways so that the asthmatic who's being intubated
probably would want to have lidocaine somewhere in the sequence so that maybe you can suppress
the reactivity that's going to happen when the endotracheal tube goes into place.
So good for ICP.
Good for reactive airways disease.
Kind of optional, and it's something that I would certainly think of using if I could.
The dose is really one milligram per kilogram.
But what I'll often do is give a milligram per kilogram back here with the appetizers
and then maybe another one per kilo somewhere in the induction sequence.
And then if it's taking some time, maybe even a third one per kilo over here, just before
I put the tube in.
And in that way, I've gotten a nice dose on board without getting a high peak level, which
can sometimes be an issue with lidocaine.
So wide combination of drugs-- appetizers, main courses, and desserts.
Choose what seems to work best for your clinical setting.
For example, if it's someone with increased ICP, I'm going to tend to prefer pentothal.
If it's someone who's an asthmatic, I'm going to tend to prefer ketamine.
If it's someone who's really cardiovascularly not in good shape, I'm going to tend to prefer
etomidate.
If it's someone I want to wake up quickly, I'm going to prefer propofol.
There are a variety of things that you have to decide as you're putting together your
combination of sedation, amnesia, analgesia, muscle relaxation before you put the tube
in.
That concludes our video on Sedatives and Analgesics for Intubation.
Thank you.
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