Task
Force
Active
ID
Short Title
The long term effects of atropine in intubating
PEDS 821 children and infants
Yes
Full Question
In infants and children requiring emergent tracheal intubation (P), does the use of atropine as a premedication (I), compared with when compared to not using atropine (C), change Survival with Favorable
neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, incidence of
cardiac arrest, Survival with favorable neurological outcome at 1 year follow up, Survival with favorable
neurological outcome at 180 days, survival to hospital discharge, Survival with favorable neurological
outcome at 90 days, Survival with favorable neurological outcome at 30 days follow up, Survival with
favorable neurological outcome at discharge, the likelihood of cardiac arrest, Likelihood of shock, incidence
of arrhythmias, the likelihood of shock, incidence of arrhythmias (O)?
PICO & Outcomes
Population: Pediatrics & Neonates
Intervention: Use of Atropine as premedication in emergency intubation
Comparison: No atropine
OUTCOMES
LEVEL OF IMPORTANCE
Likelihood/incidence of cardiac arrest
Critical (9)
Survival with favorable neurological outcome at survival to Critical (8)
 hospital discharge
 30 days follow up
 90 days follow up
 180 days follow up
 1 year follow up
Likelihood/Incidence of
Important (7)
 shock
 arrhythmias
Inclusion/Exclusion & Articles Found
 Inclusion Criteria - atropine, infants and children, emergent intubation, human
 Exclusion Criteria - case reports, animals, adults, abstracts, reviews
 No Articles initially identified = 54
 No Finally Included in Evidence Profile tables = 3 observation studies
 RCTs = 0
Non-RCTs = 3
Risk of Bias in studies
Non-RCTs = 3
Evidence profile tables
Survival In PICU
Arrhythmias
Non-RCTs = 3
Consensus on Science
For the critical outcome of survival with favorable neurological outcome, there was no study
identified that addressed this for when atropine was used for in-hospital emergent intubation.
For the critical outcome of survival to ICU discharge there was very low quality evidence
(downgraded for risk of bias & imprecision) from one pediatric observational study of in-hospital
emergent intubation (Jones, 2013, 264) of 264 infants and children, supporting the use of atropine
pre-intubation for those patients >28 days of life. The use of atropine pre-intubation for neonates
was not significantly associated with survival to ICU discharge. (Neonates: propensity score
adjusted OR 1.3, 95%CI 0.31–5.1 p=0.74; Older children OR 0.22, 95%CI 0.06–0.85, p = 0.028)
For the critical outcome of likelihood/incidence of cardiac arrest there was no study identified that
addressed this for when atropine was used for in-hospital emergent intubation
For the important outcome of likelihood/incidence of shock or arrhythmias we have identified very
low quality evidence (downgraded for risk of bias, inconsistency and imprecision) from two
pediatric observational studies. One study of 322 emergent pediatric intubations (Jones, 2013,
289) showed that the use of atropine pre-intubation was significantly associated with a reduced
incidence of any dysrhythmia (OR 0.14 95% CI 0.06–0.35) [p value removed for consistency], while
the second study of 143 emergent pediatric intubations (Fastle, 2004, 651) failed to find an
association between the pre-intubation use of atropine and a reduced incidence of bradycardia
(OR 1.11 95% CI 0.22-5.68).
Treatment Recommendations
There is insufficient evidence for the routine use of atropine as a premedication for emergent intubation in
infants and children. (Weak recommendation, Very low quality of evidence)
Knowledge Gaps
There are very few papers that have studied the effects and outcomes of atropine. Further
studies, preferably RCTs would help shed light on the effects of atropine when used in emergent
intubations in infants and children.
Specific research is required particularly for:
Survival with neurological outcomes
Incidence of Arrhythymias
Values & Preferences
In making our treatment recommendation, we placed value on causal outcomes from use of atropine.
There was only 1 study (low quality of evidence) that showed a higher ICU survival in children > 28 days
with while there was unclear evidence on the relationship between use of atropine and arrhythmias.
Therefore, due to insufficient and conflicting low quality evidence, we cannot recommend the routine
use of atropine in emergent intubation in infants and children until further studies are done.