POTD: EtomiDate or EtomiHate?

Hi everyone,

For a double dose of learning, today's extra POTD comes at the request of our wonderful PEM attending Dr. Hector Vazquez: should we be using etomidate in rapid sequence intubation (RSI) for septic pediatric patients?

Short answer? No. Long answer? It's complicated, but still no.

Etomidate's theorized effect on adrenal insufficiency = etomidate BAD

Etomidate is a bread-and-butter induction agent for us during intubation in the ED, often utilized for its hemodynamic stability and fast onset of action. However, the story started to really turn on etomidate in 2011 and 2012 when two systematic reviews and meta-analyses demonstrated that etomidate was associated with adrenal insufficiency and increased mortality in septic patients (Albert, Ariyan, & Rather, 2011; Chan, Mitchell, & Shorr, 2012). Why is this adrenal insufficiency thing such a big deal, anyways? It's because cortisol, our body's glucocorticoid that is produced by the adrenal gland, is absolutely vital during critical illness such as sepsis. Cortisol both helps maintain vascular responsiveness (good for blood pressure control in sepsis!) and has anti-inflammatory effects (good for fighting infection in sepsis!). The annoying part is that etomidate works through a cytochrome pathway that blocks conversion of cholesterol to cortisol. So more etomidate = less cortisol = adrenal insufficiency = not a good look.

Most of the adult literature on etomidate = etomidate EH BUT MOSTLY BAD

Honestly, like most of medicine, the data is controversial on the use of etomidate in sepsis in the adult literature. Even though the effect of etomidate on adrenal suppression is pretty well laid out, the question is if it is clinically significant and affects morbidity or mortality. A more recent systematic review and meta-analysis in 2021 reiterated the older meta-analyses findings, stating again an increase in adrenal suppression and mortality in septic patients (Albert & Sitaula, 2021). But, like most of medicine, many of the studies that were analyzed had some bias, some blinding blind spots, and varying definitions of all-cause mortality. A more recent RCT in 2023 even showed that there was no mortality difference between septic patients intubated with a single dose of etomidate vs. ketamine (Srivilaithon et al., 2023). All to say, the data isn't doing etomidate any favors when it comes to its use in septic adults, but it's not straight forward either. It's mostly bad, but we need better data, too. Journey with etomidate at your own risk.

Pediatric Sepsis Guidelines 2020 = etomidate BAD

Which brings us to peds patients. And make no mistake, the pediatric providers are stating it nice and clear for us: do not use etomidate in pediatric septic patients. In 2020, an expert panel released the holy grail for pediatric sepsis management, titled "Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis- Associated Organ Dysfunction in Children." Included in these guidelines are 77 evidence-based statements made up of 6 strong recommendations, 52 weak recommendations, and 9 best-practice statements. 

And here's their recommendation regarding etomidate: We suggest not to use etomidate when intubating children with septic shock or other sepsis-associated organ dysfunction (weak recommendation, low quality of evidence). So no etomidate, but a weak recommendation... why do we even trust that? Well, pediatric patients just simply don't get the same research funding and consideration that adult patients get. A lot of the recommendations thus are based off of scant data, poor data, or adult data. And with such low quality of evidence overall, they only can claim to have weak recommendations. With regards to this recommendation in particular, as of 2020, no RCTs exist in critically ill children comparing etomidate to another sedation agent. But the recommendation is going off of two observational studies that included children in their patient population and four adult RCTs. Is it the cleanest recommendation? Definitely not. But they made an educated decision and pediatric septic patients should not be getting etomidate for RSI based on this recommendation. Maybe try ketamine instead.

So what were the 6 strong recommendations then?

1. In children with septic shock, we recommend starting antimicrobial therapy as soon as possible, within 1 hour of recognition (strong recommendation, very low quality of evidence)

2. We recommend removal of intravascular access devices that are confirmed to be the source of sepsis or septic shock after other vascular access has been established and depending on the pathogen and the risks/benefits of a surgical procedure (strong recommendation, low quality of evidence)

3. In healthcare systems with no availability of intensive care and in the absence of hypotension, we recommend against bolus fluid administration while starting maintenance fluids (strong recommendation, high quality of evidence)

4. We recommend against using starches in the acute resuscitation of children with septic shock or other sepsis-associated organ dysfunction (strong recommendation, moderate quality of evidence)

5. We recommend against the routine use of inhaled nitrous oxide (iNO) in all children with sepsis-induced PARDS (strong recommendation, low quality of evidence)

6. We recommend against insulin therapy to maintain glucose target at or below 140mg/dL (7.8 mmol/L) (strong recommendation, moderate quality of evidence)

To me, it wasn't so interesting to see what was included as strong recommendations, but more to see what was not included. If it's not listed here, but is typically something you would expect to be doing for a septic patient, it is likely listed as a weak recommendation or a best-practice statement. Meaning, lots of things we don't have all the evidence for but we have all collectively decided to do them anyway.

Happy intubating,

Kelsey

Resources:

1) https://pubmed.ncbi.nlm.nih.gov/21373823/

2) https://pubmed.ncbi.nlm.nih.gov/22971586/

3) https://jtd.amegroups.org/article/view/5542/5525#B19

4) https://pubmed.ncbi.nlm.nih.gov/32912050/

5) https://www.acepnow.com/article/should-you-etomidate-me/2/

6) https://www.nature.com/articles/s41598-023-33679-x

7) https://pubmed.ncbi.nlm.nih.gov/32032273/

POTD: Bringing a needle to a knife fight

Hello friends,

For my final clinical content based POTD, I wanted to summarize the steps for a nightmare event: the pediatric can’t intubate, can’t oxygenate scenario.

Resus residents, do you ever find yourself just glossing over the small bag in the corner of the bottom drawer of the airway cart when you do your daily check? The one labeled with the piece of tape that says “jet insufflation”? Maybe in the back of your head you have a vague idea that it’s supposed to be used for a needle cric in pediatric patients below 8 years old. But that’ll probably never happen right? Well, I’m here to tell you…..you probably are right. But that doesn’t mean that we shouldn’t be prepared for it.

I remember early resus year when I would check that the things on the check list were in that bag, but not actually have the context for how it all pieced together. It wasn't until PGY-2 procedure day when me and my co-residents in our group realized what a blind spot it had been for us. What are these random small syringes with the top off? Why is there the top of an ETT just out and about in here? Well, after reviewing the steps for the procedure, hopefully you can visualize how it all comes together.

Steps

1.     Prep and drape while locating the cricothyroid membrane.

2.     Pierce the membrane with the 14G angiocath directed 30-45 degree caudally.

3.     Advance catheter over needle, hub to skin, and remove needle.

4.     Attach a 7-0 ETT adaptor to top of a 3mL syringe with plunger taken out and attach this apparatus to the catheter.

5.     Attach a BVM to ETT adaptor.

6.     Take a deep breath (but don’t forget to also give your patient one), you did it.

It’s a relatively simple procedure, just with insanely high stakes.

Because I’m very much a visual learner:

Here’s a quick 1:52 min video: https://www.youtube.com/watch?v=F_PV7N2c2pQ. Note how the video does it is probably slightly different than how we would with our own makeshift kit here. Sorry for the potato quality but it’s short and gets the point across.

And lastly, I wanted to summarize a recent article written in June (the First10EM link below) that actually advocates doing a surgical approach with a scalpel and not going down the needle cric route for kids like what is traditionally taught to us. The author was also featured on this week’s episode of EMRAP going over this topic. Basically multiple professional societies have come out with contradictory guidelines over the use of needle vs surgical cric, which is not helpful. Data is super limited because of the rarity of this event in this population. Pediatric case reports seem to demonstrate a lack of success of the needle approach as the first line and that complications are to be expected even when the airway is established. This is seen again and again in adult studies as well.

The author then advocates that having the peds surgical cric approach in your toolbox is the best guarantee of achieving a definitive airway in this scenario with the least complications.

In children less than eight years old, the cricoid membrane may be too small so the horizontal incision step is discarded. There is also a higher risk of transecting the entire trachea with the horizontal incision. Instead in the peds surgical approach, you would just do a vertical cut through the trachea (though no more than 2 tracheal rings as this can make repair afterwards more difficult).

Would love to know what other peds providers think about this stance. It does seem like it is branching a little bit farther than what we’re comfortable with, but this is where the art of medicine comes in because the paucity of data out there.

References

https://www.ncbi.nlm.nih.gov/books/NBK537350/

https://first10em.com/the-pediatric-cant-intubate-cant-oxygenate-scenario-use-a-knife/

https://www.tamingthesru.com/blog/acmc/needle-cricothyrotomy

Breathe easy friends!

Intubating Asthmatic Patients

Asthma is Greek for panting, which is a fitting translation for a patient that presents with a severe asthma exacerbation. We try to avoid intubating these patients because they are prone to compilations such as pneumothorax, mucus plugging, and increased morbidity and mortality. 

However, there are specific situations when you may consider intubating an asthmatic patient. One reason is that your patient may not be improving despite maximal medical therapy, such as BIPAP, albuterol, ipratropium, magnesium, epinephrine/terbutaline, ketamine, etc. Another reason is that your patient may now be altered, and have worsening work of breathing, and vital sign abnormalities. Remember that a “silent chest” is a poor prognostic indicator; you may not hear wheezing because they are not moving any air. 

If you choose to intubate, there are tricks to maximize your success and optimize your management of your patient on the vent. 

• Use a large ETT (8-9) because it reduces airflow resistance and can facilitate procedures later (such as bronchoscopy). 

• Ketamine is a useful induction agent because of its bronchodilatory effects. It may also be useful if you choose delayed sequence intubation. 

• High airway pressures can cause hypotension after intubation, so consider giving volume if there is a current or prior history of hypotension. 

• If hemodynamics are compromised consider giving an epinephrine drip. It is considered a systemic bronchodilator that can provide hemodynamic support as well as bronchodilation. 

• Keep a low respiratory rate when bagging or on the vent (6-8 breaths/min). Giving them time to exhale will decrease the chances of air trapping and pneumothorax. Another way to do this is to increase the I:E time (1:4 or 1:5). 

• If the vent is alarming, troubleshoot (DOPES mnemonic) but be suspicious for mucus plugs, pneumothorax, or breath stacking. If they are breath stacking, disconnect them from the vent and push on their chest to help them fully exhale.  

A quick note about auto-PEEP and breath stacking: Auto-PEEP refers to trapping gas in the lungs during respiration. This occurs when one breath can’t be fully exhaled before the next inhalation. This trapped gas causes additional positive pressure, known as “auto-PEEP” in the chest which is typically higher than the PEEP set on the ventilator. This process predisposes patients to develop a pneumothorox. 

Thanks for reading!

Ariella