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Site ApplicabilityThis document is applicable in all sites managing pediatric patients with suspected/confirmed COVID-19.Practice Level/CompetenciesIntubation of the suspected/confirmed COVID-19 patient is a specialized skill and should be performed by the Most Qualified Physician (MQP), with assistance from the most experienced RT, and most experienced RN. The MQP may include an Anesthesiologist if an airway is pre-assessed as difficult, or to act as the primary physician who will perform the intubation.FOR SUPPORT AT ANY TIME. Establish contact with Pediatric Intensive Care Unit (PICU) via BC Patient Transfer Network (PTN) Phone: 604-215-5911 Toll Free: 1-866-233-2337 or Virtual Health Policy Statement(s) To limit healthcare team exposure to particles and aerosols of suspected/confirmed COVID-19 patient intubation will be performed with as few members of the healthcare team as possible.Intubation is an Aerosol Generating Medical Procedure (AGMP), therefore the Personal Protection Equipment (PPE) necessary for droplet contact and airborne precautions shall be enforced. Special attention will be given to minimize aerosol exposure where possible.PrinciplesParental presence should be determined by local infection control guidelinesThere are differences between suggested guidelines for intubation in pediatric versus adult patients related to disease process and physiology Most experienced person available to perform intubation (goal of first pass success) - identify pediatric airway team composition at local institution in advance of neededEstablish early and ongoing contact with Pediatric Intensive Care Unit (PICU) via Patient Transfer Network (PTN) or Virtual Health Use single patient isolation room, preferably negative pressure if availablePPE for AGMPs (Airborne Precautions, in addition to Droplet & Contact Precaution) Minimize exposed personnel with an Inside Team and an Outside TeamAll equipment and medications (including resuscitation and post intubation sedation medications) in the room prior to procedureOptimize patient’s status pre-intubationWe strongly advise organizing simulation sessions to practice your locally adapted procedure with your teamIndexPatient and Team PreparationMedication SuggestionsIntubation/Ventilation Reference Chart Protected airway checklists (set-up, equipment and medications)Intubation Checklist with EquipmentAirway Documentation SheetIntubation Gear DropExample of Team PositioningReferencesPatient and Team PreparationPatient PreparationConfirm need for intubation - can patient be supported with high flow or BiPAP?Assess airway difficulty/IV access - is intraosseous access needed? Plan for transfer post procedure to higher level of careSingle patient isolation room, negative pressure room preferredHave intubation team begin PPE donning prior to procedureOptimize physiology - consider fluid bolus and/or early use of vasopressorsTeam Preparation Recommend 2 teams if possible (one inside room and one outside room) Most Qualified Physician (MQP) to perform intubation Utilize PPE supervisor to ensure correct technique during donning procedure outside roomHave all equipment and medications needed ready to be brought into the room (for procedure and for possible resuscitation)Use the method of intubation most likely to result in first pass success (video laryngoscope may reduce team exposure if operator has expertise in its use)Review Intubation checklist with team in room before procedureEnsure all team members are aware of plans and contingenciesOral intubation always, preferably cuffed endotracheal tube (ETT)In adults, it is recommended avoid positive pressure ventilation (bagging) if at all possible to reduce aerosolization of viral particles. While also preferred in children, children desaturate rapidly once sedated/paralyzed,some pediatric patients may need positive pressure ventilation (PPV) prior to intubation.Use 2-person technique, gentle bagging pressure. Ensure both the self inflating bag or Jackson Rees (J-R) circuit have an expiratory limb HME filter.Post ProcedureTeam to remain in room until clearance of particles from the air if not using negative pressure room. Clarify the timing in your hospitalPortable Chest X-Ray (CXR) - protect staff using appropriate precautions during the CXRTitrate FiO2 for sats 90-95%/ ETCO2 40-50Establish ongoing sedation (see medication suggestions)Obtain blood gas (capillary or venous is adequate) once patient stabilized, tube secured, ventilator settings stabilizedDoffing of PPE preferably observed and guided by PPE supervisor (preferably in anteroom)Document procedure Update PICU in receiving hospital – request advice on ventilator settings (see C. Intubation/ Ventilation Reference Chart )Ventilation Tidal Volume: Protective lung strategies. TV targets of 5-8 mls/kg (Ideal Body Weight)Use 3-6mls/kg if compliance is poorInspiratory Time (Ti): refer to the chart for Ti ranges. A common error made in pediatric ventilation is neonatal Ti settings dialed into the ventilator. Circuit choice (Ventilator dependent. Clarify what your center has): Patient WeightCircuit Choice< 10 kgNeonatal circuit in Neonatal mode10 to 15 kgAdult circuit but put the ventilator in Pediatric Mode> 15 kgAdult circuit in Adult ModeMinute Ventilation: use the table values to estimate the patient’s starting minute ventilation. Titrate to the end tidal CO2 or capillary/ venous/ arterial gasTarget plateau pressure <30 cm H2O PaCO2 40-50 mmHg is acceptable7.25 preferredFowler R. 2020Medication SuggestionsPremedications to ConsiderFluid bolus (20ml/kg crystalloid). Administer only if needed (hypotension, hypovolemia)Consider early initiation of vasopressors (epinephrine) if any hemodynamic instability. Epinephrine range 0.05 to 2mcg/kg/min. Discuss with PICU. Atropine 0.02mg/kg (most likely to be needed in patients less than 1 year or demonstrated vagal response with coughing). Routine administration is not recommended. If cardiac arrest, use epinephrine 0.01mg/kg (use standard 0.1mg/ml concentration) Sedation/ AnalgesiaKetamine 1-2 mg/kgParalysisRocuronium 1mg/kg (preferred)Succinylcholine 2mg/kgPost Intubation Ongoing Sedation/ ParalysisMorphine infusion (range 10-40 mcg/kg/hour) plus bolus of 50 mcg/kg prnMidazolam infusion (range 60-180 mcg/kg/hour) plus bolus of 50 mcg/kg prnRocuronium 1mg/kg q45 min prn (if unable to establish ventilator synchrony or oxygenation with spontaneous breathing)Intubation/Ventilation Reference ChartCHBC Equipment and Initial Ventilator Settings for Pediatric Patients Suspected COVID-19Adapted from The Pediatric Advanced Life Support Provider ManualProtected airway checklists (Page 1 of 3)Adapted from: Helman, A. Kovacs, G. Episode 140 COVID-19 Part 4 – Protected Intubation. Emergency Medicine Cases. March, 2020. 12 Apr 2020Protected airway checklists (Page 2 of 3)Protected airway checklists (Page 3 of 3)Intubation Checklist with EquipmentAirway Documentation Sheet (Page 1 of 2)F. Airway Documentation Sheet (Page 2 of 2)Bishop J, Z. Hillberry, Skippen,P 2020Intubation Gear DropExample of Team Positioning631825000ReferencesGuideline ReferencesInterim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines?-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians K, & Nagler J. Advances in Emergent Airway Management in Pediatrics. Emergency Medicine Clinics of North America. 37 (2019) 473–491 Pediatric Drug Dosage Guidelines, 7th Edition, Editor: Roberta Esau BSc (Pharm.), under the direction of the C & W Pharmacy, Therapeutics and Nutrition Committee. Public Health Agency of Canada, COVID-19 Clinical Care Guidance Working Group. Fowler R, Hatchette T, Salvadori M, Ofner M, Poliquin G, Yeung T & Brooks J. Clinical Management of Patients with Moderate to Severe COVID-19 – Interim Guidance. April 2, 2020. Accessed April 6, 2020. Zaritsky A, Chernow B. Use of catecholamines in pediatrics. Journal of Pediatrics. 1984;105:341–350 Tool ReferencesChrimes N. The Vortex: a universal 'high-acuity implementation tool' for emergency airway management. British journal of anaesthesia. 2016;117 Suppl 1:i20-i7Galante L. (2015). Management of the Difficult Airway.Critical Care Nursing Clinics of North America, Volume 27, Issue 1, 2015, Pages 55-66Heart and Stroke Foundation of Canada. (2016).?Pediatric advanced life support: provider manual. Ottawa.Kneyber, M., de Luca, D., Calderini, E., Jarreau, P. H., Javouhey, E., Lopez-Herce, J., Hammer, J., Macrae, D., Markhorst, D. G., Medina, A., Pons-Odena, M., Racca, F., Wolf, G., Biban, P., Brierley, J., Rimensberger, P. C., & section Respiratory Failure of the European Society for Paediatric and Neonatal Intensive Care (2017). Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC).?Intensive care medicine,?43(12), 1764–1780. Long, E., Fitzpatrick, P., Cincotta, D. R., Grindlay, J., & Barrett, M. J. (2016). A randomised controlled trial of cognitive aids for emergency airway equipment preparation in a Paediatric Emergency Department.?Scandinavian journal of trauma, resuscitation and emergency medicine,?24, 8.Luten, R. C., Zaritsky, A., Wears, R., & Broselow, J. (2007). The Use of the Broselow Tape in Pediatric Resuscitation.?Academic Emergency Medicine,?14(5), 500–501. doi: 10.1197/j.aem.2007.02.015Matettore, A. , Ramnarayan, P. , Jones, A. , Randle, E. , Lutman, D. , O’Connor, M. & Chigaru, L. (2019). Adverse Tracheal Intubation-Associated Events in Pediatric Patients at Nonspecialist Centers. Pediatric Critical Care Medicine, 20(6), 518–526. Nagler, J. & Cheiftez, I.(2019) Initiating mechanical ventilation in children. In Randolph, A. (ED)., Uptodate. Retrieved April 10, 2020. From Nishisaki A, Turner DA, Brown CA 3rd, et al; National Emergency Airway Registry for Children (NEAR4KIDS); Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: A national emergency airway registry for children: Landscape of tracheal intubation in 15 PICUs. Crit Care Med 2013; 41:874–885Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Brewster D, Chrimes N, Do T, Fraser K, Groombridge C, Higgs A, Humar M, Leeuwenburg T, McGloughlin S, Newman F, Nickson C, Rehak A, Vokes D & Gatward J. The Medical Journal of Australia - Preprint only - Version 2, updated 1 April 2020. Sherren P, Tricklebank S & Glover G. Development of a standard operating procedure and checklist for rapid sequence induction in the critically ill.. Scandinavian Journal of Trauma Resuscitation and Emergency Medicine.?2014;?22: 41.??Published online 2014 Sep 11 Walls, R. M., & Murphy, M. F. (2012).?Manual of emergency airway management. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.Contributing authors: Jeff Bishop MDZachary Hilberry RRTHeather May MDAlex McLean MDRobyn Candell RNAmanda Barclay MDAllon Beck MDPaul Colella MDLogan Lee MDDr. Greg McKelvie (Pharmacy)Angela Morehouse RNTricia Chevalier RNJennifer Smitten MDTom McLaughlin MDPavan Judge MDSim Grewal MDMarina Kirincic RNRoxanne Carr PharmD, BCPS, FCSHPKyle Collins PharmDLynn MacIsaac RRTVi Ean Tan MDCheryl Peters MDPeter Skippen MDVersion HistoryDATEDOCUMENT NUMBER and TITLEACTION TAKEN16-Apr-2020C-0506-07-60630 Regional Guideline: Intubation Of Suspected/Confirmed COVID-19 Pediatric PatientDeveloped by Regional COVID Response Working Group; Approved by Professional Practice DirectorDisclaimerThis document is intended for use?within?BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.?This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.? ................
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