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The Optimal Preoxygenation Target to Avoid Desaturation During Pediatric Rapid Sequence Intubation


Jennifer Noce BA, NRP, CCEMTP, FP-C, CCP-C David Olvera BA, NRP, FP-C, CMTE Daniel Davis MD


Background: Rapid sequence intubation (RSI) is a critical procedure in the resuscitation of critically ill and injured patients but carries an important risk of oxygen desaturation. In the adult population, a target preoxygenation threshold of >93% has been defined. However, it is not known whether this is an appropriate target for pediatric patients.

Objective: To define a target preoxygenation threshold for pediatric RSI.

Methods: Our air medical agency includes 150 bases, with a flight RN/flight paramedic crew configuration. The pediatric RSI protocol includes the use of etomidate or ketamine for induction and either succinylcholine or rocuronium for paralysis. Up to 120 data elements are entered into the Institutions Airway Database for each RSI procedure. For this analysis, all pediatric patients (age <18 years) undergoing RSI between January 2015 and September 2019 were included. Separate analysis was performed for infants (0-2 years), young children (3-8 years), and older children (9-17 years). Patients were stratified by highest pre-attempt SpO2 value, with the rate of desaturation identified as the primary outcome measure. Desaturation was defined as decrease in SpO2 to <94% or a continued decrease by at least 2% if pre-attempt SpO2 value was <94%. A graphical analysis was performed to identify an inflection point below which substantially higher desaturation rates were observed. The desaturation rate for patients with pre-attempt SpO2 values above that threshold were compared to those below that threshold using chi-square analysis, with significance was set at p<0.05.

Results: A total of 1,116 patients were identified over the 57-month period (infant n=247, young children n=250, older children n=619). A clear desaturation rate inflection point was observed with pre-attempt SpO2 values of 97% or greater. For patients with pre-attempt SpO2 values of <97%, the desaturation rate was 59.2% as compared to 12.8% with pre-attempt SpO2 values of 97% or greater (OR 9.8, 95% CI 6.9-14.1, p<0.0001). These results were similar across the three age groups.

Conclusions: These data support a higher preoxygenation target of 97% or greater with pediatric RSI. Limitations include the observational nature of the analysis and the possibility that lower pre-attempt SpO2 is a surrogate for more a difficult airway.

Click below to read the full research paper published by Science Direct and the Air Medical Journal, Volume 41, Issue 1, January-February 2022, Page 26