Delayed sequence intubation with ketamine in 2 critically ill children

Hypoxia is a common complication during the emergent intubation of children. Several approaches may help avoid hypoxia, including semiupright patient positioning, adequate preoxygenation, and nasal cannula apneic oxygenation. Delayed sequence intubation (DSI) is a strategy to facilitate preoxygenationwhen standard efforts using supplemental oxygen with nonrebreather (NRB) mask are not successful. In DSI, the sedative agent ketamine is administered to facilitate effective preoxygenation via NRB mask or continuous positive airway pressure (CPAP), followed by the delayed administration of a neuromuscular blocking agent once adequate preoxygenation has been achieved. A recent prospective, observational, multicenter study of adults demonstrated that DSI using ketamine facilitated increased oxygenation saturations during preoxygenation in adults [1]. To date there have only been 2 descriptions of the use of pediatric DSI in the literature, both in normotensive patients [2,3]. We present the successful use of ketamine for DSI in 2 critically ill hypoxic children in shock requiring emergent intubation. Delayed sequence intubation is a strategy that should be considered for children who are not able to be preoxygenated for intubation using conventional strategies. © 2015 Elsevier Inc. All rights reserved.