word: regional guideline: intubation of suspected...

REGIONAL GUIDELINE: INTUBATION OF SUSPECTED/CONFIRMED COVID-19 PEDIATRIC PATIENT

DOCUMENT TYPE: GUIDELINESite Applicability

This 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.

Principles

Parental presence should be determined by local infection control guidelines There 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 needed Establish 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 available PPE for AGMPs (Airborne Precautions, in addition to Droplet & Contact Precaution) Minimize exposed personnel with an Inside Team and an Outside Team All equipment and medications (including resuscitation and post intubation sedation

medications) in the room prior to procedure Optimize patient’s status pre-intubation We strongly advise organizing simulation sessions to practice your locally adapted

procedure with your team

Index

A. Patient and Team PreparationC-0506-07-60630 Published Date: 27-Apr-2020

of 16 Review Date: 27-Apr-2023 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/infection-control/personal-protective-equipment

http://www.phsa.ca/health-professionals/professional-resources/office-of-virtual-health/covid-19-virtual-health-toolkit

http://www.bcehs.ca/our-services/programs-services/patient-transfer-services


http://www.phsa.ca/health-professionals/professional-resources/office-of-virtual-health/covid-19-virtual-health-toolkit



DOCUMENT TYPE: GUIDELINE

B. Medication Suggestions

C. Intubation/Ventilation Reference Chart

D. Protected airway checklists (set-up, equipment and medications)

E. Intubation Checklist with Equipment

F. Airway Documentation Sheet

G. Intubation Gear Drop

H. Example of Team Positioning

I. References

A. Patient and Team Preparation

Patient Preparation Confirm need for intubation - can patient be supported with high flow or BiPAP?

C-0506-07-60630 Published Date: 27-Apr-2020 of 16 Review Date: 27-Apr-2023 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.


DOCUMENT TYPE: GUIDELINE Assess airway difficulty/IV access - is intraosseous access needed? Plan for transfer post procedure to higher level of care Single patient isolation room, negative pressure room preferred Have intubation team begin PPE donning prior to procedure Optimize physiology - consider fluid bolus and/or early use of vasopressors

Team 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 room Have 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 procedure Ensure all team members are aware of plans and contingencies Oral 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 Procedure Team to remain in room until clearance of particles from the air if not using negative

pressure room. Clarify the timing in your hospital Portable Chest X-Ray (CXR) - protect staff using appropriate precautions during the CXR Titrate FiO2 for sats 90-95%/ ETCO2 40-50



DOCUMENT TYPE: GUIDELINE Establish ongoing sedation (see medication suggestions) Obtain blood gas (capillary or venous is adequate) once patient stabilized, tube secured,

ventilator settings stabilized Doffing 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 poor Inspiratory 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 Weight Circuit Choice< 10 kg Neonatal circuit in Neonatal mode10 to 15 kg Adult circuit but put the ventilator in Pediatric Mode> 15 kg Adult circuit in Adult Mode

Minute Ventilation: use the table values to estimate the patient’s starting minute ventilation. Titrate to the end tidal CO2 or capillary/ venous/ arterial gas

Target plateau pressure <30 cm H2O PaCO2 40-50 mmHg is acceptable

7.25 preferred

Fowler R. 2020

B. Medication Suggestions

Premedications to Consider Fluid 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.



DOCUMENT TYPE: GUIDELINE 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/ Analgesia Ketamine 1-2 mg/kg

Paralysis Rocuronium 1mg/kg (preferred) Succinylcholine 2mg/kg

Post Intubation Ongoing Sedation/ Paralysis Morphine infusion (range 10-40 mcg/kg/hour) plus bolus of 50 mcg/kg prn Midazolam infusion (range 60-180 mcg/kg/hour) plus bolus of 50 mcg/kg prn Rocuronium 1mg/kg q45 min prn (if unable to establish ventilator synchrony or oxygenation

with spontaneous breathing)




C. Intubation/Ventilation Reference ChartCHBC Equipment and Initial Ventilator Settings for Pediatric Patients Suspected COVID-19

Adapted from The Pediatric Advanced Life Support Provider ManualC-0506-07-60630 Published Date: 27-Apr-2020 of 16 Review Date: 27-Apr-2023

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.



D. Protected 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. https://emergencymedicinecases.com/covid-19-protected-intubation. Accessed 12 Apr 2020


https://emergencymedicinecases.com/covid-19-protected-intubation



E. Intubation Checklist with Equipment

C-0506-07-60630 Published Date: 27-Apr-2020 of 16 Review Date: 27-Apr-2023




F. Airway Documentation Sheet (Page 1 of 2)




F. Airway Documentation Sheet (Page 2 of 2)

Bishop J, Z. Hillberry, Skippen,P 2020




G. Intubation Gear Drop

C-0506-07-60630 Published Date: 27-Apr-2020 of 16 Review Date: 27-Apr-2023




H. Example of Team Positioning




I. ReferencesGuideline 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 https://doi.org/10.1161/CIRCULATIONAHA.120.047463

Miller 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. http://www.pedmed.org/DrugApp/index.html

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. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/clinical-management-covid-19.html

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-i7

Galante L. (2015). Management of the Difficult Airway.Critical Care Nursing Clinics of North America, Volume 27, Issue 1, 2015, Pages 55-66

Heart 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.2007.02.015

Matettore, 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 https://www.uptodate.com/contents/initiating-mechanical-ventilation-in-children


https://www.uptodate.com/contents/initiating-mechanical-ventilation-in-children

https://www.uptodate.com/contents/initiating-mechanical-ventilation-in-children

https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/clinical-management-covid-19.html

https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/clinical-management-covid-19.html

http://www.pedmed.org/DrugApp/index.html

https://doi.org/10.1161/CIRCULATIONAHA.120.047463


DOCUMENT TYPE: GUIDELINENishisaki 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; 41:874–885

Safe 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. https://www.safeairwaysociety.org/covid19/

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 https://www.safeairwaysociety.org/public/105/files/SAS%20COVID%201_2.pdf

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 MD

Logan Lee MDDr. Greg McKelvie (Pharmacy)Angela Morehouse RNTricia Chevalier RNJennifer Smitten MDTom McLaughlin MDPavan Judge MDSim Grewal MD

Marina Kirincic RNRoxanne Carr PharmD, BCPS, FCSHPKyle Collins PharmDLynn MacIsaac RRTVi Ean Tan MDCheryl Peters MDPeter Skippen MD

Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN16-Apr-2020 C-0506-07-60630 Regional Guideline: Intubation

Of Suspected/Confirmed COVID-19 Pediatric Patient

Developed by Regional COVID Response Working Group; Approved by Professional Practice Director

DisclaimerThis 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.


https://www.safeairwaysociety.org/public/105/files/SAS%20COVID%201_2.pdf

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