Premedication for nonemergency endotracheal intubation in the neonate

Feasibility of monitoring stress using skin conduction measurements during intubation of newborns

The objective of this study was to assess the feasibility of monitoring stress responses in newborns during naso-tracheal intubation after two different premedication regimens, using skin conductance measurements (SCM). Twenty-two newborns were randomised and premedicated with morphine + vecuronium or propofol. SCM (peaks/s) were collected prior to, during and after the procedure. Threshold for interpreting responses as stressful was 0.21 peaks/s. Intubation conditions and physiological parameters were registered. Intubation conditions were good in all newborns. Administration of morphine (range 1.4-10.3 min) before administration of vecuronium did not affect SCM when a stressful stimulus was applied. Within 1.6 min (range 0.8-3 min) after administration of vecuronium, SCM disappeared in 10 of 11 newborns. Propofol reduced SCM in 10 of 11 newborns at the first attempt. Further attempts were associated with increasing SCM, mostly above a threshold of 0.21 peaks/s. There were no significant changes in physiological parameters during the procedure for either premedication regimen.

CONCLUSION

The variation in SCM between individual newborns limits the usefulness of SCM as stress monitor during intubation. The use of neuromuscular blockers for premedication precludes monitoring of SCM completely in newborns.

WHAT IS KNOWN

Skin conductance measurements have been used successfully to monitor pain in awake newborn infants.

WHAT IS NEW

Premedicated newborns display significant interindividual variation in skin conductance measurements during an intubation procedure. Neuromuscular blockade causes skin conductance measurements to disappear completely.

The therapeutic value of atropine for critical care intubation

Recent studies of atropine during critical care intubation (CCI) have revealed that neonates frequently experience bradycardia, are infrequently affected by ventricular arrhythmias and conduction disturbances and deaths have not been reported in a series of studies. The indiscriminate use of atropine is unlikely to alter the outcome during neonatal CCI other than reducing the frequency of sinus tachycardia. In contrast, older children experience a similar frequency of bradycardia to neonates and are more frequently affected by ventricular arrhythmias and conduction disturbances. Mortality during CCI is in the order of 0.5%. Atropine has a beneficial effect on arrhythmias and conduction disturbances and may reduce paediatric intensive care unit mortality. The use of atropine for children >1 month of age may positively influence outcomes beyond a reduction in the frequency of sinus bradycardia. There is indirect evidence that atropine should be used for intubation during sepsis. Atropine should be considered when using suxamethonium. The reliance on heart rate as the sole measure of haemodynamic function during CCI is no longer justifiable. Randomised trials of atropine for mortality during CCI in general intensive care unit populations are unlikely to happen. As such, future research should be focused on establishing of a gold standard for haemodynamic decompensation for CCI. Cardiac output or blood pressure are the most likely candidates. The 'lost beat score' requires development but has the potential to be developed to provide an estimation of risk of haemodynamic decompensation from ECG data in real time during CCI.

Painful procedures and analgesia in the NICU: what has changed in the medical perception and practice in a ten-year period?

OBJECTIVE

To compare the use of analgesia versus neonatologists' perception regarding analgesic use in painful procedures in the years 2001, 2006, and 2011.

METHODS

This was a prospective cohort study of all newborns admitted to four university neonatal intensive care units during one month in 2001, 2006, and 2011. The frequency of analgesic prescription for painful procedures was evaluated. Of the 202 neonatologists, 188 answered a questionnaire giving their opinion on the intensity of pain during lumbar puncture, tracheal intubation, mechanical ventilation, and postoperative period using a 10-cm visual analogic scale (VAS; pain >3cm).

RESULTS

For lumbar puncture, 12% (2001), 43% (2006), and 36% (2011) were performed using analgesia. Among the neonatologists, 40-50% reported VAS >3 for lumbar puncture in all study periods. For intubation, 30% received analgesia in the study periods, and 35% (2001), 55% (2006), and 73% (2011) of the neonatologists reported VAS >3 and would prescribe analgesia for this procedure. As for mechanical ventilation, 45% (2001), 64% (2006), and 48% (2011) of patient-days were under analgesia; 56% (2001), 57% (2006), and 26% (2011) of neonatologists reported VAS >3 and said they would use analgesia during mechanical ventilation. For the first three post-operative days, 37% (2001), 78% (2006), and 89% (2011) of the patients received analgesia and more than 90% of neonatologists reported VAS >3 for major surgeries.

CONCLUSIONS

Despite an increase in the medical perception of neonatal pain and in analgesic use during painful procedures, the gap between clinical practice and neonatologist perception of analgesia need did not change during the ten-year period.

Do small doses of atropine (<0.1 mg) cause bradycardia in young children?

OBJECTIVE

To determine the heart rate response to atropine (<0.1 mg) in anaesthetised young infants.

DESIGN

Prospective, observational and controlled.

SETTING

Elective surgery.

PATIENTS

Sixty unpremedicated healthy infants less than 15 kg were enrolled. Standard monitoring was applied. Anaesthesia was induced by mask with nitrous oxide (66%) and oxygen (33%) followed by sevoflurane (8%).

INTERVENTIONS

Intravenous (IV) atropine (5 µg/kg) was flushed into a fast flowing IV. The ECG was recorded continuously from 30 s before the atropine until 5 min afterwards.

MAIN OUTCOME MEASURES

The incidence of bradycardia and arrhythmias was determined from the ECGs by a blinded observer.

RESULTS

The median (IQR) age was 6.5 (4-12) months and the mean (95% CI) weight was 8.6 (8.1 to 9.1) kg. The mean (95% CI) dose of atropine was 40.9 (37.3 to 44) µg. Bradycardia did not occur. Two infants developed premature atrial contractions and one developed a premature ventricular contraction. When compared with baseline values, heart rate increased by 7% 30 s after atropine, 14% 1 min after atropine and 25% 5 min after atropine. Twenty-nine infants (48%) experienced tachycardia (>20% above baseline rate) after atropine lasting 222.7 s (range 27.9-286). The change in heart rate 5 min after atropine was inversely related to the baseline heart rate.

CONCLUSIONS

The upper 95% CI for the occurrence of bradycardia in the entire population of infants based on a zero incidence in this study is 5%. These results rebut the notion that atropine <0.1 mg IV causes bradycardia in young infants.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov #NCT01819064.

Effect of premedication regimen on infant pain and stress response to endotracheal intubation

OBJECTIVE

(1) Evaluate the effect of different medications on pain and stress in neonates during nonemergent endotracheal intubation; (2) determine whether gestational age affects medication use; (3) determine whether better sedation results in a decrease in the number of attempts and/or total time for the procedure.

STUDY DESIGN

Prospective observational study. Infant responses were measured using a clinical pain scale and blood glucose, a biochemical marker of acute stress.

RESULT

A total of 166 infants were included, with adjusted gestational ages 24 to 44 weeks at the time of procedure. Premedication regimens included no medication ('none,' 27%), morphine (19%), morphine+midazolam (11%), fentanyl (14%), fentanyl+midazolam (19%) and midazolam alone (10%). Fentanyl+midazolam resulted in lower pain scores and less increase in blood glucose (both P<0.0001). No other regimen was different from 'none'. The most immature infants were less likely to receive premedication (P=0.023), although their pain scores and blood glucose responses were similar to more mature infants. None of the medication regimens reduced the total procedure time (P=0.55) or the number of attempts (P=0.145).

CONCLUSION

Only fentanyl+midazolam significantly attenuated both the clinical pain score and the increase in blood glucose. Less mature infants had responses similar to those of more mature infants, but were less likely to receive premedication. None of the regimens decreased the time or number of attempts required for successful intubation.

Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study

OBJECTIVES

Tracheal intubation in PICUs is often associated with adverse tracheal intubation-associated events. There is a paucity of data regarding medication selection for safe tracheal intubations in PICUs. Our primary objective was to evaluate the association of medication selection on specific tracheal intubation-associated events across PICUs.

DESIGN

Prospective observational cohort study.

SETTING

Nineteen PICUs in North America.

SUBJECTS

Critically ill children requiring tracheal intubation.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Using the National Emergency Airway Registry for Children, tracheal intubation quality improvement data were prospectively collected from July 2010 to March 2013. Patient, provider, and practice characteristics including medications and dosages were collected. Adverse tracheal intubation-associated events were defined a priori. A total of 3,366 primary tracheal intubations were reported. Adverse tracheal intubation-associated events occurred in 593 tracheal intubations (18%). Fentanyl and midazolam were the most commonly used induction medications (64% and 58%, respectively). Neuromuscular blockade was used in 92% of tracheal intubation with the majority using rocuronium (64%) followed by vecuronium (20%). Etomidate and succinylcholine were rarely used (1.6% and 0.7%, respectively). Vagolytics were administered in 37% of tracheal intubations (51% in infants; 28% in > 1 yr old; p < 0.001). Ketamine was used in 27% of tracheal intubations but more often for tracheal intubations in patients with unstable hemodynamics (39% vs 25%; p < 0.001). However, ketamine use was not associated with lower prevalence of new hypotension (ketamine 8% vs no ketamine 14%; p = 0.08).

CONCLUSIONS

In this large, pediatric multicenter registry, fentanyl, midazolam, and ketamine were the most commonly used induction agents, and the majority of tracheal intubations involved neuromuscular blockade. Ketamine use was not associated with lower prevalence of hypotension.

Application of Lidocaine Spray for Tracheal Intubation in Neonates - A Clinical Trial Study

Background:

Tracheal intubation is extremely distressing, painful, and may influence heart rate and blood pressure. Sedatives, analgesics, and muscle relaxants are not commonly used for intubation in neonates.

Objectives:

This study aimed to evaluate the effects of lidocaine spray as a non-intravenous drug before neonatal intubation on blood pressure, heart rate, oxygen saturation and time of intubation.

Patients and Methods:

In a randomized, controlled study each neonate was randomly assigned to one of the two study groups by staffs who were not involved in the infant's care. The allocation concealment was kept in an opaque sealed envelope, and the investigators, the patient care team, and the assessors were blinded to the treatment allocation. The selected setting was NICU unit of a teaching hospital in Ilam city, Iran and participants were 60 neonates with indication of tracheal intubation with gestational age > 30 weeks. Patients in the treatment group received lidocaine spray and the placebo group received spray of normal saline prior to intubation. Main outcome measurements were the mean rates of blood pressure, heart rate, oxygen saturation, intubation time and lidocaine side effects were measured before and after intubation.

Results:

Totally 60 newborns including 31 boys and 29 girls were entered into the study (drug group n = 30; placebo group n = 30). Boy/girl ratio in treatment and placebo groups were 1.3 and 0.88, respectively. Mean age ± SD of participants was 34.1 ± 24.8 hours (treatment: 35.3 ± 25.7; placebo: 32.9 ± 24.3; P < 0.0001). Mean weight ± SD of neonates was 2012.5 ± 969 g. Application of lidocaine spray caused a significant reduction of mean intubation time among treatment group compared with placebo group (treatment: 15.03 ± 2.2 seconds; placebo: 18.3 ± 2.3 seconds; P < 0.0001). Mean blood pressure, heart rate and oxygen saturation rate, among neonates in treatment group was reduced after intubation compared with their relevant figures before intubation; however, their differences were not statistically significant except for mean oxygen saturation rate that was reduced significantly in placebo group. No side effects were observed during study.

Conclusions:

Though the current study revealed some promising results in the application of lidocaine spray during neonatal intubation without any considerable side effects; however, the current investigation could only be considered as a pilot study for further attempts in different locations with higher sample sizes and in different situations.

Factors Associated with Adverse Events during Tracheal Intubation in the NICU

BACKGROUND

The incidence of adverse tracheal intubation-associated events (TIAEs) and associated patient, practice, and intubator characteristics in the neonatal intensive care unit (NICU) setting are unknown.

OBJECTIVES

To determine the incidence of adverse TIAEs and to identify factors associated with TIAEs in the NICU.

METHODS

Single-site prospective observational cohort study of infants who were intubated in a level 4 referral NICU between September 1, 2011 and November 30, 2013. A standardized pediatric airway registry was implemented to document patient, practice, and intubator characteristics and outcomes of intubation encounters. The primary outcome was adverse TIAEs.

RESULTS

Adverse TIAEs occurred in 153 of 701 (22%) tracheal intubation encounters. Factors that were independently associated with lower incidence of TIAEs in logistic regression included attending physician (vs. resident; odds ratio (OR) 0.4, 95% CI: 0.16, 0.98) and use of paralytic medication (OR 0.45, 95% CI: 0.25, 0.81). Severe oxygen desaturations (≥ 20% decrease in oxygen saturation) occurred in 51.1% of encounters and were more common in tracheal intubations performed by residents (62.8%), compared to fellows (43.2%) or attendings (47.5%; p = 0.008).

CONCLUSIONS

Adverse TIAEs and severe oxygen desaturation events are common in the NICU setting. Modifiable risk factors associated with TIAEs identified include intubator training level and use of paralytic medications.

Risk Factors for Failed Tracheal Intubation in Pediatric and Neonatal Critical Care Specialty Transport

Abstract Objective. Nearly 200,000 pediatric and neonatal transports occur in the United States each year with some patients requiring tracheal intubation. First-pass intubation rates in both pediatric and adult transport literature are variable as are the factors that influence intubation success. This study sought to determine risk factors for failed tracheal intubation in neonatal and pediatric transport. Methods. A retrospective chart review was performed over a 2.5-year period. Data were collected from a hospital-based neonatal/pediatric critical care transport team that transports 2,500 patients annually, serving 12,000 square miles. Patients were eligible if they were transported and tracheally intubated by the critical care transport team. Patients were categorized into two groups for data analysis: (1) no failed intubation attempts and (2) at least one failed intubation attempt. Data were tabulated using Epi Info Version 3.5.1 and analyzed using SPSSv17.0. Results. A total of 167 patients were eligible for enrollment and were cohorted by age (48% pediatric versus 52% neonatal). Neonates were more likely to require multiple attempts at intubation when compared to the pediatric population (69.6% versus 30.4%, p = 0.001). Use of benzodiazepines and neuromuscular blockade was associated with increased successful first attempt intubation rates (p = 0.001 and 0.008, respectively). Use of opiate premedication was not associated with first-attempt intubation success. The presence of comorbid condition(s) was associated with at least one failed intubation attempt (p = 0.006). Factors identified with increasing odds of at least one intubation failure included, neonatal patients (OR 3.01), tracheal tube size ≤ 2.5 mm (OR 3.78), use of an uncuffed tracheal tube (OR 6.85), and the presence of a comorbid conditions (OR 2.64). Conclusions. There were higher rates of tracheal intubation failure in transported neonates when compared to pediatric patients. This risk may be related to the lack of benzodiazepine and neuromuscular blocking agents used to facilitate intubation. The presence of a comorbid condition is associated with a higher risk of tracheal intubation failure.

Remifentanil for endotracheal intubation in premature infants: A randomized controlled trial

Objective:

Endotracheal intubation is a common procedure in neonatal care. The objective of this study was to determine whether the premedication with remifentanil before intubation has analgesic effects in newborn infants.

Methods:

A total of 40 premature infants who needed endotracheal intubation for intubation-surfactant-extubation method were randomly assigned in two groups of an equal number at two university hospitals. The control group was given 10 μg/kg atropine IV infusions in 1 min and then 2 ml normal saline. In the case group, the atropine was given with the same method and then remifentanil was administered 2 μg/kg IV infusions in 2 min.

Findings:

For remifentanil and control groups, the mean birth weight were 1761 ± 64 and 1447 ± 63 grams (P = 0.29), and the mean gestational ages were 31.69 ± 3.5 and 30.56 ± 2.8 weeks (P = 0.28), respectively. Using premature infant pain profile score, infants who received remifentanil felt significantly less pain than the control group (15.1 ± 1.6 vs. 7.5 ± 1.4; P < 0.001). There were no significant differences in the duration of endotracheal intubation procedure (20.8 ± 6 vs. 22.8 ± 7.3 s; P = 0.33), the number of attempts for successful intubation and oxygen desaturation between groups.

Conclusion:

Premedication with remifentanil has good analgesic effects for endotracheal intubation in premature infants without significant derangements in mean blood pressure and oxygen saturation.

Impact of premedication on neonatal intubations by pediatric and neonatal trainees

OBJECTIVE

To determine if premedication and training level affect the success rates of neonatal intubations.

STUDY DESIGN

We retrospectively reviewed a hospital-approved neonatal intubation database from 2003 to 2010. Intubation success rate was defined as the number of successful intubations divided by the total number of attempts, and then compared by trainee's experience level and the use of premedication. Premedication regimen included anticholinergic, analgesic and muscle relaxant agents.

RESULT

There were 169 trainees who completed 1071 successful intubations with 2694 attempts. The median success rate was 36% by all trainees, and improved with training level from 29% for pediatric trainees to 50% for neonatal trainees (P<0.001). Premedication was used in 58% of intubation attempts. The median success rate was double with premedication (43% versus 22%, P<0.001).

CONCLUSION

Neonatal endotracheal intubation is a challenge for trainees. Intubation success rates progressively improve with experience. Premedication is associated with improved success rates for all training levels.

Assessment of atropine-sufentanil-atracurium anaesthesia for endotracheal intubation: an observational study in very premature infants

Background

Premedication before neonatal intubation is heterogeneous and contentious. The combination of a short acting, rapid onset opioid with a muscle relaxant is considered suitable by many experts. The purpose of this study was to describe the tolerance and conditions of intubation following anaesthesia with atropine, sufentanil and atracurium in very premature infants.

Methods

Monocentric, prospective observational study in premature infants born before 32 weeks of gestational age, hospitalised in the NICU and requiring semi-urgent or elective intubation. Intubation conditions, heart rate, pulse oxymetry (SpO₂), arterial blood pressure and transcutaneous PCO₂ (TcPCO₂) were collected in real time during 30 minutes following the first drug injection. Repeated physiological measurements were analysed using mixed linear models.

Results

Thirty five intubations were performed in 24 infants with a median post conceptional age of 27.6 weeks and a median weight of 850 g at the time of intubation. The first attempt was successful in 74% and was similar for junior (75%) and senior (74%) operators. The operator rated conditions as “excellent” or “good” in 94% of intubations. A persistent increase in TcPCO₂ as compared to baseline was observed whereas other vital parameters showed no significant variations 5, 10, 15 and 30 minutes after the first drug injection. Eighteen (51%) desaturations (SpO2 less than or equal to 80% for more than 60 seconds) and 2 (6%) bradycardia (heart rate less than100 bpm for more than 60 seconds) were observed.

Conclusion

This drug combination offers satisfactory success rate for first attempt and intubation conditions for the operator without any significant change in heart rate and blood pressure for the patient. However it is associated with frequent desaturations and a possible persistent hypercapnia. SpO₂ and PCO₂ can be significantly modified during neonatal intubation and should be cautiously followed in this high-risk population.

Remifentanil versus morphine-midazolam premedication on the quality of endotracheal intubation in neonates: a noninferiority randomized trial

OBJECTIVE

To compare remifentanil and morphine-midazolam for use in nonurgent endotracheal intubation in neonates.

STUDY DESIGN

In this prospective noninferiority randomized trial, newborns of gestational age ≥28 weeks admitted in the neonatal intensive care unit requiring an elective or semielective endotracheal intubation were divided into 2 groups. One group (n = 36) received remifentanil (1 μg/kg), and the other group (n = 35) received morphine (100 μg/kg) and midazolam (50 μg/kg) at a predefined time before intubation (different in each group), to optimize the peak effect of each drug. Both groups also received atropine (20 μg/kg). The primary outcome was to compare the conditions of intubation, and the secondary outcome was to compare the duration of successful intubation, physiological variables, and pain scores between groups for first and second intubation attempts. Adverse events and neurologic test data were reported.

RESULTS

Intubation with remifentanil was not inferior to that with morphine-midazolam. At the first attempted intubation, intubation conditions were poor in 25% of the remifentanil group and in 28.6% of the morphine-midazolam group (P = .471). For the second attempt, conditions were poor in 28.6% of the remifentanil group, compared with 10% of the morphine-midazolam group (P = .360). The median time to successful intubation was 33 seconds (IQR, 24-45 seconds) for the remifentanil group versus 36 seconds (IQR, 25-59 seconds) for the morphine-medazolam group (P = .359) at the first attempt and 45 seconds (IQR, 35-64 seconds) versus 56 seconds (IQR, 44-68 seconds), respectively, for the second attempt (P = .302). No significant between-group difference was reported for hypotension, bradycardia, or adverse events.

CONCLUSION

In our cohort, remifentanil was at least as effective as the morphine-midazolam regimen for endotracheal intubation. Thus, premedication using this very-short-acting opioid can be considered in urgent intubations and is advantageous in rapid extubation.

[Implementation of a specific premedication protocol for tracheal intubation in the delivery room. Practice in two level-III hospitals]

Tracheal intubation in neonates is a painful procedure performed daily in the delivery room despite the widespread development of noninvasive ventilation. Specific analgesia is not commonly performed. The objective of this observational study was to compare practices between two level-III centers: one with a specific protocol for premedication before tracheal intubation of newborns in the delivery room, the other without.

RESULTS

One hundred and fifteen neonates were intubated in the delivery room and included over a 4-month period: 25% of them received specific premedication before intubation, exclusively in the center with the protocol. None of the extreme premature neonates (age≤28 gestational weeks) received analgosedation before the procedure. Nalbuphine, midazolam, and sufentanil were mainly used, via the intravenous or intrarectal route. Infants receiving a premedication were significantly heavier and had a greater gestational age than the others (1500 g [range, 1180-2260 g] vs. 1170 [range, 860-1680 g] P=0.003, and 31 GW [range, 29-34 GW] vs. 29 [range, 27-32 GW] P=0.014, respectively). Most pediatricians (85-100%) favored a specific protocol for sedation before tracheal intubation. Implementation of a specific protocol allows specific analgesia to be implemented for newborns undergoing tracheal intubation. Further studies should be conducted to determine the best strategies for pain management during tracheal intubation of neonates, especially in the delivery room.

A novel maturation function for clearance of the cytochrome P450 3A substrate midazolam from preterm neonates to adults

BACKGROUND AND OBJECTIVE

Major changes in cytochrome P450 (CYP) 3A activity may be expected in the first few months of life with, later, relatively limited changes. In this analysis we studied the maturation of in vivo CYP3A-mediated clearance of midazolam, as model drug, from preterm neonates of 26 weeks gestational age (GA) to adults.

METHODS

Pharmacokinetic data after intravenous administration of midazolam were obtained from six previously reported studies. Subjects were premature neonates (n = 24; GA 26-33.5 weeks, postnatal age (PNA) 3-11 days, and n = 24; GA 26-37 weeks, PNA 0-1 days), 23 children after elective major craniofacial surgery (age 3-23 months), 18 pediatric intensive-care patients (age 2 days-17 years), 18 pediatric oncology patients (age 3-16 years), and 20 healthy male adults (age 20-31 years). Population pharmacokinetic modeling with systematic covariate analysis was performed by use of NONMEM v6.2.

RESULTS

Across the entire lifespan from premature neonates to adults, bodyweight was a significant covariate for midazolam clearance. The effect of bodyweight was best described by use of an allometric equation with an exponent changing with bodyweight in an exponential manner from 0.84 for preterm neonates (0.77 kg) to 0.44 for adults (89 kg), showing that the most rapid maturation occurs during the youngest age range.

CONCLUSIONS

An in-vivo maturation function for midazolam clearance from premature neonates to adults has been developed. This function can be used to derive evidence-based doses for children, and to simulate exposure to midazolam and possibly other CYP3A substrates across the pediatric age range in population pharmacokinetic models or physiologically based pharmacokinetic models.

Sedation of newborn infants for the INSURE procedure, are we sure?

Background. Neonatal intubation is a stressful procedure that requires premedication to improve intubation conditions and reduce stress and adverse physiological responses. Premedication used during the INSURE (INtubation, SURfactant therapy, Extubation) procedure should have a very short duration of action with restoration of spontaneous breathing within a few minutes. Aims. To determine the best sedative for intubation during the INSURE procedure by systematic review of the literature. Methods. We reviewed all relevant studies reporting on premedication, distress, and time to restoration of spontaneous breathing during the INSURE procedure. Results. This review included 12 studies: two relatively small studies explicitly evaluated the effect of premedication (propofol and remifentanil) during the INSURE procedure, both showing good intubation conditions and an average extubation time of about 20 minutes. Ten studies reporting on fentanyl or morphine provided insufficient information about these items. Conclusions. Too little is known in the literature to draw a solid conclusion on which premedication could be best used during the INSURE procedure. Both remifentanil and propofol are suitable candidates but dose-finding studies to detect effective nontoxic doses in newborns with different gestational ages are necessary.

Ketamine and atropine decrease pain for preterm newborn tracheal intubation in the delivery room: an observational pilot study

AIM

Various analgesic strategies are used before tracheal intubation of preterm newborns in the delivery room, due to the lack of a standard protocol and difficult venous access. This study evaluated the feasibility and efficacy of short venous catheter insertion and immediate ketamine analgesia for tracheal intubation of preterm newborns at birth in the delivery room.

METHODS

Prospective observational pilot study, with ketamine and atropine used at the paediatrician's discretion. Pain score, heart rate, SpO2 nadirs, procedure duration and neonatal intensive care unit morbidity were recorded.

RESULTS

Fifty-seven consecutive preterm newborns were included between January I and June 30, 2012: 15 in the no analgesia group and 39 in the intravenous ketamine group. Short catheter insertion failed in three newborns. The pain score was lower during laryngoscopy in the ketamine group (4 ± 0.7 vs. 2.9 ± 3.2 in the no analgesia group, p < 0.001). The heart rate nadir during tracheal intubation was 150.7 ± 29.6 bpm (vs. 112.6 ± 35.5 bpm in the no analgesia group, p < 0.01). Surfactant therapy was administered to 79.5% of newborns in the ketamine group (vs. 92.3%, p = 0.29) in the first 30 min of life.

CONCLUSION

Short venous catheter insertion with immediate ketamine analgesia plus atropine for tracheal intubation of preterm newborns in the delivery room was effective in decreasing pain and preventing vagal bradycardia.

Clinical evaluation of propofol as sedative for endotracheal intubation in neonates

AIM

To determine the effects of propofol for endotracheal intubation in neonates in daily clinical practice.

METHODS

We prospectively studied the pharmacodynamic effects of intravenous propofol administration in neonates who needed endotracheal intubation at the neonatal intensive care unit.

RESULTS

Propofol was used for 62 intubations in neonates with postmenstrual ages ranging from 24 + 3 weeks to 44 + 5 weeks and bodyweights ranging from 520 to 4380 g. A 2 mg/kg bodyweight propofol starting dose was sufficient in 37% of patients; additional propofol was needed less often on the first postnatal day. The mean amount of propofol used was 3.3 (±1.2) mg/kg. The success rate of intubation depended on the experience of the physician and was related to the total administered amount of propofol. Hypotension occurred in 39% of patients and occurred more often at the first postnatal day. In 15% of procedures, propofol mono therapy was insufficient.

CONCLUSION

This study shows that high doses of propofol are needed to reach effective sedation in neonates for intubation, with hypotension as a side effect in a considerable percentage of patients. Further research in newborn patients needs to identify optimal propofol doses and risk factors for hypotension.

Sedation and analgesia to facilitate mechanical ventilation

Regardless of age, health care professionals have a professional and ethical obligation to provide safe and effective analgesia to patients undergoing painful procedures. Historically, newborns, particularly premature and sick infants, have been undertreated for pain. Intubation of the trachea and mechanical ventilation are ubiquitous painful procedures in the neonatal intensive care unit that are poorly assessed and treated. The authors review the use of sedation and analgesia to facilitate endotracheal tube placement and mechanical ventilation. Controversies regarding possible adverse neurodevelopmental outcomes after sedative and anesthetic exposure and in the failure to treat pain is also discussed.

Premedication for neonatal endotracheal intubation: results from the epidemiology of procedural pain in neonates study

OBJECTIVES

To describe the frequency and nature of premedications used prior to neonatal endotracheal intubation; to confront observed practice with current recommendations; and to identify risk factors for the absence of premedication.

DESIGN, SETTING, AND PATIENTS

Data concerning intubations were collected prospectively at the bedside as part of an observational study collecting around-the-clock data on all painful or stressful procedures performed in neonates during the first 14 days of their admission to 13 tertiary care units in the region of Paris, France, between 2005 and 2006.

INTERVENTION

Observational study.

MEASUREMENTS AND MAIN RESULTS

Specific premedication prior to endotracheal intubation was assessed. Ninety one intubations carried out on the same number of patients were analyzed. The specific premedication rate was 56% and included mostly opioids (67%) and midazolam (53%). Compared with recent guidance from the American Academy of Pediatrics, used premedications could be classified as "preferred" (12%), "acceptable" (18%), "not recommended" (27%), and "not described" (43%). In univariate analysis, infants without a specific premedication compared with others were younger at the time of intubation (median age: 0.7 vs. 2.0 days), displayed significantly more frequent spontaneous breathing at the time of intubation (31% vs. 12%) and a higher percentage of analgesia for all other painful procedures (median values: 16% vs. 6%). In multivariate analysis, no factor remained statistically significant.

CONCLUSIONS

Premedication use prior to neonatal intubation was not systematically used and when used it was most frequently inconsistent with recent recommendations. No patient- or center-related independent risk factor for the absence of premedication was identified in this study.

Procedural pain in neonates: the state of the art in the implementation of national guidelines in Italy

BACKGROUND

National and international guidelines have been published on pain control and prevention in the newborn, but data on compliance with these guidelines are lacking.

AIM

To document current hospital practices for analgesia at neonatal intensive care units (NICUs) 5 years after national guidelines were published in Italy.

METHODS

A computer-based questionnaire was sent to all registered Italian level II and level III NICUs to investigate their routine pain control practices.

MAIN OUTCOME MEASURES

The analgesia and sedation currently used for invasive procedures as compared with best practices.

RESULTS

The questionnaire was returned by 103 of the 118 NICUs (87.3%), most of which (85.4%) knew of the national guidelines on procedural pain control and prevention, and used some analgesic measures during invasive procedures. One or more nonpharmacological interventions were only used routinely by 64.1% of the NICUs for heel pricks and venipuncture, 56.0% for percutaneous insertion of central catheters, 69.7% for nasal CPAP, and 62.4% for eye tests to screen for retinopathy of prematurity. Pain medication was routinely administered at 34.3% NICUs for tracheal intubation, 46.6% for mechanical ventilation (MV), 12.9% for tracheal aspiration, 71.4% for chest tube insertion, 33.0% for lumbar puncture, and 64.0% for postoperative pain. Pain was routinely monitored at only 22.7% of the units during MV, 12.1% for nCPAP, and 21.8% postoperatively.

CONCLUSION

This survey showed that most Italian NICUs provide some form of analgesia and sedation for invasive procedures in accordance with national guidelines, but their routine adherence to best practices for pain control and monitoring is still suboptimal.

Premedication for neonatal intubation: Current practice in Saudi Arabia

BACKGROUND

Despite strong evidence of the benefits of rapid sequence intubation in neonates, it is still infrequently utilized in neonatal intensive care units (NICU), contributing to avoidable pain and secondary procedure-related physiological disturbances.

OBJECTIVES

The primary objective of this cross-sectional survey was to assess the practice of premedication and regimens commonly used before elective endotracheal intubation in NICUs in Saudi Arabia. The secondary aim was to explore neonatal physicians' attitudes regarding this intervention in institutions across Saudi Arabia.

METHODS

A web-based, structured questionnaire was distributed by the Department of Pediatrics, Umm Al Qura University, Mecca, to neonatal physicians and consultants of 10 NICUs across the country by E-mail. Responses were tabulated and descriptive statistics were conducted on the variables extracted.

RESULTS

85% responded to the survey. Although 70% believed it was essential to routinely use premedication for all elective intubations, only 41% implemented this strategy. 60% cited fear of potential side effects for avoiding premedication and 40% indicated that the procedure could be executed more rapidly without drug therapy. Treatment regimens varied widely among respondents.

CONCLUSION

Rates of premedication use prior to non-emergent neonatal intubation are suboptimal. Flawed information and lack of unified unit policies hampered effective implementation. Evidence-based guidelines may influence country-wide adoption of this practice.

Premedication for intubation with morphine causes prolonged depression of electrocortical background activity in preterm infants

BACKGROUND

Sedative and analgesic medications are used in critically ill newborns, but little is known about their effects on electrocortical activity in preterm infants. We hypothesized that morphine might induce prolonged neurodepression, independent of blood pressure, as compared with rapid sequence induction/intubation(RSI).

METHODS

Of 34 infants enrolled in a randomized controlled trial (RCT) comparing RSI (including thiopental 2-3 mg/kg and remifentantil 1 mcg/kg) with morphine (0.3 mg/kg) as premedication for intubation, 28 infants (n = 14 + 14; median gestational age 26.1 wk and postnatal age 138 h) had continuous two-channel amplitude-integrated electroencephalogram (aEEG/EEG) and blood pressure monitoring during 24 h after the intubation. Thirteen infants not receiving any additional medication constituted the primary study group. Visual and quantitative analyses of aEEG/EEG and blood pressure were performed in 3-h epochs.

RESULTS

RSI was associated with aEEG/EEG depression lasting <3 h. Morphine premedication resulted in aEEG/EEG depression with more discontinuous background and less developed cyclicity for 24 h, and during the first 9 h, interburst intervals (IBI) were significantly increased as compared with those of RSI treatment. The difference was not related to blood pressure.

CONCLUSION

Premedication with morphine is associated with prolonged aEEG/EEG depression independent of blood pressure changes and may not be optimal for short procedures.

The lost art of intubation: assessing opportunities for residents to perform neonatal intubation

OBJECTIVE

The objective of this study is to assess the opportunities afforded to and competence of pediatric residents in performing neonatal endotracheal intubations.

STUDY DESIGN

The records of all intubations performed on neonates over a 3-year period at a university-based birthing hospital were reviewed to assess the relationships between outcomes, types of providers and the setting of intubations.

RESULT

A total of 785 attempts were made during 362 intubations. Pediatric residents were given the opportunity to intubate 38% of the cohort (n=137) and were successful on 21% of the attempts. Residents were more likely to perform intubation in the neonatal intensive care unit (vs delivery room; P<0.001), in non-emergency situations (P<0.001), and on older (P<0.001) and larger (P=0.07) infants.

CONCLUSION

Opportunities for residents to intubate neonates were few and their success rate was low. In the current care paradigm, it is doubtful if trainees can be sufficiently skilled in endotracheal intubation during residency. Residents that plan to pursue procedure-intensive subspecialties may benefit from other models for training.

Premedication for neonatal intubation in Australia and New Zealand: a survey of current practice

AIM

This study aims to describe the current approach to intubation premedication in neonatal intensive care units (NICUs) in Australia and New Zealand.

METHODS

A literature review regarding intubation premedication in the newborn was carried out to inform questionnaire design. A web-based survey of 28 NICUs and two neonatal emergency transport services was conducted and supplemented by telephone contact to ensure completion.

RESULTS

All the tertiary NICUs and neonatal emergency transport services in Australia and New Zealand use premedication for elective intubation of neonates. Eighty per cent of units have a written policy. There were 28 of 30 units (93%) that use muscle relaxants, mostly suxamethonium. The choice of sedative medication is varied.

CONCLUSIONS

  Australian and New Zealand neonatal units have a high use of intubation premedication including muscle relaxants, but vary considerably in their choice of sedative medication.

Initial respiratory support of preterm infants: the role of CPAP, the INSURE method, and noninvasive ventilation

This article explores the potential benefits and risks for the various approaches to the initial respiratory management of preterm infants. The authors focus on the evidence for the increasingly used strategies of initial respiratory support of preterm infants with continuous positive airway pressure (CPAP) beginning in the delivery room or very early in the hospital course and blended strategies involving the early administration of surfactant replacement followed by immediate extubation and stabilization on CPAP. Where possible, the evidence referenced in this review comes from individual randomized controlled trials or meta-analyses of those trials.

Effects of endotracheal intubation and surfactant on a 3-channel neonatal electroencephalogram

OBJECTIVE

To evaluate the effects of surfactant administration on the neonatal brain using 3-channel neonatal electroencephalography (EEG).

STUDY DESIGN

A prospective cohort of 30 infants had scalp electrodes placed to record brain waves using 3-channel EEG (Fp1-O1, C3-C4, and Fp2-O2). Sixty-second EEG epochs were collected from a 10-minute medication-free baseline, during premedication for endotracheal intubation, at surfactant administration, and at 10, 20, and 30 minutes after surfactant administration for amplitude comparisons. Oxygen saturation and heart rate were monitored continuously. Blood pressure and transcutaneous carbon dioxide were recorded every 5 minutes.

RESULTS

Eighteen of 29 infants (62%) exhibited brain wave suppression on EEG after surfactant administration (P ≤ .008). Four of those 18 infants did not receive premedication. Nine infants exhibited evidence of EEG suppression during endotracheal intubation, all of whom received premedication before intubation. Five infants had EEG suppression during endotracheal suctioning. Oxygen saturation, heart rate, and blood pressure were not independent predictors of brain wave suppression.

CONCLUSION

Eighteen of 29 intubated infants (62%) had evidence of brain wave suppression on raw EEG after surfactant administration. Nine patients had evidence of brief EEG suppression with endotracheal intubation alone, a finding not previously reported in neonates. Intubation and surfactant administration have the potential to alter cerebral function in neonates.

Rapid sequence induction is superior to morphine for intubation of preterm infants: a randomized controlled trial

OBJECTIVES

To compare rapid sequence intubation (RSI) premedication with morphine for intubation of preterm infants.

STUDY DESIGN

Preterm infants needing semi-urgent intubation were enrolled to either RSI (glycopyrrolate, thiopental, suxamethonium, and remifentanil, n = 17) or atropine and morphine (n = 17) in a randomized trial. The main outcome was "good intubation conditions" (score ≤10 assessed with intubation scoring), and secondary outcomes were procedural duration, physiological and biochemical variables, amplitude-integrated electroencephalogram, and pain scores.

RESULTS

Infants receiving RSI had superior intubation conditions (16/17 versus 1/17, P < .001), the median (IQR) intubation score was 5 (5-6) compared with 12 (10.0-13.5, P < .001), and a shorter procedure duration of 45 seconds (35-154) compared with 97 seconds (49-365, P = .031). The morphine group had prolonged heart rate decrease (area under the curve, P < .009) and mean arterial blood pressure increase (area under the curve, P < .005 and %change: mean ± SD 21% ± 23% versus -2% ± 22%, P < .007) during the intubation, and a subsequent lower mean arterial blood pressure 3 hours after the intubation compared with baseline (P = .033), concomitant with neurophysiologic depression (P < .001) for 6 hours after. Plasma cortisol and stress/pain scores were similar.

CONCLUSION

RSI with the drugs used can be implemented as medication for semi-urgent intubation in preterm infants. Because of circulatory changes and neurophysiological depression found during and after the intubation in infants given morphine, premedication with morphine should be avoided.

Intubation training in neonatal patients: a review of one trainee's first 150 procedures

BACKGROUND

The experience in performing intubation procedures gained by a single operator has been previously reported for adult, but not for neonatal patients.

AIM

In order to evaluate the process of skill acquisition, we reviewed the first 150 neonatal tracheal intubations performed by a pediatric trainee.

METHODS

For logbook purposes, a pediatric trainee prospectively recorded all neonatal tracheal intubation procedures that she performed during a 5-year training period.

RESULTS

During the study period, Nicoletta Doglioni performed for 152 intubation procedures. Of the 152 procedures, the author was successful on 120 (79%) occasions. Of these, 77 (64%) were performed on the first attempt, and 43 (36%) on the second attempt. Author successful intubation improved by the training year 1 (67%) to training year 2 (79%), 3 (77%), 4 (80%) and 5 (91%), respectively.

CONCLUSIONS

Intubation success rate progressively improved with training year experience. A recommended level of proficiency, defined as 90% of procedure success, was obtained after 100 attempts suggesting that a significant amount of experience is needed for obtaining proficiency in neonatal intubation.

Propofol versus midazolam for intubating preterm neonates: a randomized controlled trial

OBJECTIVE

The ideal combination of premedication for neonatal tracheal intubation has not been established. The aim of this preliminary study was to compare the intubation conditions between propofol and midazolam as premedication for tracheal intubation in neonates.

STUDY DESIGN

A double-blinded, randomized, controlled trial was performed, and 20 preterm neonates (28 to 34 week) underwent tracheal intubation following the use of remifentanil associated to either propofol (n = 10) or midazolam (n = 10). Intubation conditions were scored according to a four-point scale.

RESULT

According to the main outcome measured (identification of a 50% difference in the intubation conditions), there were no differences regarding the number of attempts and the overall intubation conditions among the groups (P = 1.00).

CONCLUSION

Both combinations of premedications have no differences regarding the quality of intubation, which could be of clinical interest. Besides midazolam, propofol could be a valid alternative as hypnotic for premedication for endotracheal intubation in neonates.

Thiopentone elimination in newborn infants: exploring Michaelis-Menten kinetics

BACKGROUND

Thiopentone elimination has been described using Michaelis-Menten pharmacokinetics in adults after prolonged infusion or overdose, but there are few reports of elimination in neonates.

METHODS

Time-concentration profiles for neonates (n=37) given single-dose thiopentone were examined using both first-order (constant clearance) and mixed-order (Michaelis-Menten) elimination processes using nonlinear mixed effects models. These profiles included a 33-week post-menstrual age (PMA) neonate given an overdose. A two-compartment mamillary model was used to fit data. Parameter estimates were standardized to a 70 kg person using allometric models.

RESULTS

There were 197 observations available for analysis from neonates with a mean post-menstrual age of 35 (SD 4.5) weeks and a mean weight of 2.5 (SD 0.9) kg. They were given a mean thiopentone dose of 3 (SD 0.4) mg/kg as a rapid bolus. Clearance at 26 weeks PMA was 0.015 l/min/70 kg and increased to 0.119 l/min/70 kg by 42 weeks PMA. The maximum rate of elimination (V(max)) at 26 weeks PMA was 0.22 mg/min/70 kg and increased to 4.13 mg/min/70 kg by 42 weeks PMA. These parameter estimates are approximately 40% adult values at term gestation. The Michaelis constant (K(m)) was 28.3 [between subject variability (BSV) 46.4%, 95% confidence interval (CI) 4.49-99.2] mg/l; intercompartment clearance was 0.44 (BSV 97.5%, 95% CI 0.27-0.63) l/min/70 kg; central volume of distribution was 46.4 (BSV 29.2%, 95% CI 41.7-59.8) l/70 kg; peripheral volume of distribution was 95.7 (BSV 70.3%, 95% CI 61.3-128) l/70 kg.

CONCLUSIONS

Both first-order and mixed-order processes satisfactorily described elimination. First-order elimination adequately described the time-concentration profile in the premature neonate given an overdose. Clearance is immature in the pre-term neonate although there is rapid maturation around 40 weeks PMA, irrespective of post-natal age.

Rocuronium for nonemergent intubation of term and preterm infants

OBJECTIVE

The aim of this study was to analyze clinical characteristics of rocuronium as premedication for nonemergent intubation in infants.

STUDY DESIGN

Preterm infants requiring nonemergent intubation were randomized to receive atropine and fentanyl with or without rocuronium. Outcomes, patient characteristics and intubator's experience were noted. Onset, duration and degree of clinical paralysis were recorded for rocuronium group and for older infants receiving rocuronium per unit protocol.

RESULT

Forty-four intubations were randomized (20 rocuronium, 24 control). Groups were similar in chronological and corrected gestational age, weight and intubator's experience. Successful intubation on first attempt was achieved in 35% of intubations under rocuronium vs 8% of controls; rocuronium was the only significant variable by logistic regression (odds ratio=0.052, P=0.029). Complete paralysis was reported in 80% of 57 rocuronium intubations; onset ranged from 14 to 178 s (65.9±43.4), and duration from 1 to 60 min (16.3±13.5).

CONCLUSION

Rocuronium facilitated successful intubation and provided clinical paralysis quickly in most infants.