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Correspondence to Dr Constantinos Kanaris, Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; [email protected]

Introduction

Intubation of critically ill children is scary, rarely practised outside the paediatric intensive care unit and can be risky business (even in large tertiary centres).1 Intubation allows us to definitively protect the airway. If necessary, this enables us to provide intensive organ support that would otherwise be impossible in a child that is either awake or so obtunded that he or she is at risk of airway obstruction. Failure to achieve situational control and basic physiological therapeutic endpoints is associated with a rapidly rising mortality in critically unwell and injured children. This article aims to address how to plan a rapid successful intubation and identify potential pitfalls.

Effective multidisciplinary collaboration between emergency clinicians, anaesthetists, paediatricians and nursing staff is crucial for a good outcome. The proliferation of paediatric critical care retrieval teams in the UK allows telephone support of clinicians at the bedside (in a non tertiary setting) until the retrieval team arrives. The onus of safe intubation, however, very much remains with the referring team, as it is usually detrimental to the child to wait for a retrieval team before intubation.

Centralisation of paediatric care in the UK has reduced the amount of elective anaesthesia (especially <3 years), neonatal intubations and trauma cases being managed in the DGH, reducing opportunities for practice and familiarity of paediatric intubation in all members of the team.

Planning/preparation/action

A lot needs to happen quickly in these scenarios, and it can be different every time (based on the patient, situation and staffing). Risks are judged with patient requirements and timescales.

Broadly, the process can be broken down as shown in box 1.

Box 1

Timeline of the intubation process

  • Assessment (airway breathing circulation as per advanced paediatric life support).

  • Resuscitation.

  • Location (accident and emergency department/high dependency unit/theatres/paediatric intensive care unit transfer to another location (risk vs benefit).

  • Preparation (always use a checklist).

  • Equipment.

  • Drugs.

  • Team.

  • Action and response.

  • Postintubation and debrief.

More detail on some of these areas is provided further; it is essential you have induction and (ideally simulation) in the actual work area/system you are working in.

Resuscitation: Resuscitate before you intubate

Unless the patient has...

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