1
|
van der Vaart M, Hauck AG, Mansfield R, Adams E, Bhatt A, Cobo MM, Crankshaw D, Dhami A, Hartley C, Monk V, Evans Fry R, Moultrie F, Robinson S, Yong J, Poorun R, Baxter L, Slater R. Parental experience of neonatal pain research while participating in the Parental touch trial (Petal). Pain 2024; 165:1727-1734. [PMID: 38284396 PMCID: PMC11247449 DOI: 10.1097/j.pain.0000000000003177] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/30/2023] [Accepted: 12/10/2023] [Indexed: 01/30/2024]
Abstract
ABSTRACT Parental involvement in neonatal comfort care is a core component of family-centred care. Yet, parents experience a range of positive and negative feelings when providing pain-relieving interventions for their infants. Parents of infants who participated in the Parental touch trial ( Petal ), a multicentre randomised controlled trial investigating the impact of gentle parental touch on neonatal pain, were asked to complete an anonymous survey. This survey aimed to (1) explore parent-reported motivations in deciding to participate in the Petal trial; (2) understand parent-reported experiences related to trial participation; (3) understand parents' willingness to participate in future studies; and (4) evaluate parent-reported feelings while they were delivering a gentle touch intervention either before or after a clinically necessary blood test. One hundred six parents (1 parent per infant) took part in the survey. Primary motivators for participation were altruistic. Parents most frequently reported that they wanted their child to take part in the research because it has a potential benefit to babies in the future and because they wanted to improve scientific understanding. Parents reported that providing gentle touch to their children during painful procedures was associated with positive emotions, such as feeling "useful" (64%) and "reassured" (53%). Furthermore, nearly all parents (98%) were pleased to have participated in the Petal trial and would consider, or maybe consider, participating in further research studies. These results underscore the importance of structuring trials around parental involvement and providing opportunities for parents to be involved in providing comfort to their infants during necessary painful clinical procedures.
Collapse
Affiliation(s)
| | | | - Roshni Mansfield
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Maria M. Cobo
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Colegio de Ciencias Biologicas y Ambientales, Universidad San Francisco de Quito USFQ, Quito, Ecuador
| | - Daniel Crankshaw
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Amraj Dhami
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Vaneesha Monk
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Shellie Robinson
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Jean Yong
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Ravi Poorun
- University of Exeter Medical School, Exeter, United Kingdom
- Children's Services, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
2
|
Petrov I, Stankovic Z, Soldatovic I, Tomic A, Simic D, Milenovic M, Milovanovic V, Nikolic D, Jovicic N. Difficult Airway Prediction in Infants with Apparently Normal Face and Neck Features. J Clin Med 2024; 13:4294. [PMID: 39124561 PMCID: PMC11313502 DOI: 10.3390/jcm13154294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objectives: Prediction of a difficult airway during pre-anesthetic evaluation is of great importance because it enables an adequate anesthetic approach and airway management. As there is a scarcity of prospective studies evaluating the role of anthropometric measures of the face and neck in predicting difficult airways in infants with an apparently normal airway, we aimed to identify the aforementioned predictors of difficult facemask ventilation and intubation in infants. Methods: A prospective, observational study that included 97 infants requiring general endotracheal anesthesia was conducted. Anthropometric and specific facial measurements were obtained before ventilation and intubation. Results: The incidence of difficult facemask ventilation was 15.5% and 38.1% for difficult intubation. SMD (sternomental distance), TMA (tragus-to-mouth angle distance), NL (neck length) and mouth opening were significantly lower in the difficult facemask ventilation group. HMDn (hyomental distance in neutral head position), HMDe (hyomental distance in neck extension), TMD (thyromental distance), SMD, mandibular development and mouth opening were significantly different in the intubation difficulty group compared to the non-difficult group. HMDn and HMDe showed significantly greater specificities for difficult intubation (83.8% and 76.7%, respectively), while higher sensitivities were observed in TMD, SMD and RHSMD (ratio of height to SMD) (89.2%, 75.7%, and 70.3%, respectively). Regarding difficult facemask ventilation, TMA showed greater sensitivity (86.7%) and SMD showed greater specificity (80%) compared to other anthropometric parameters. In a multivariate model, BMI (body mass index), COPUR (Colorado Pediatric Airway Score), BOV (best oropharyngeal view) and TMA were found to be independent predictors of difficult intubation, while BMI, ASA (The American Society Physical Status Classification System), CL (Cormack-Lehane Score), TMA and SMD predicted difficult facemask ventilation. Conclusions: Preoperative airway assessment is of great importance for ventilation and intubation. Patient's overall condition and facial measurements can be used as predictors of difficult intubation and ventilation.
Collapse
Affiliation(s)
- Ivana Petrov
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| | - Zorana Stankovic
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
| | - Ivan Soldatovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| | - Ana Tomic
- University Clinical Centre of Serbia, Pasterova 2, 11000 Belgrade, Serbia;
| | - Dusica Simic
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| | - Miodrag Milenovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
- University Clinical Centre of Serbia, Pasterova 2, 11000 Belgrade, Serbia;
| | - Vladimir Milovanovic
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| | - Dejan Nikolic
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| | - Nevena Jovicic
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| |
Collapse
|
3
|
Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth 2024; 132:124-144. [PMID: 38065762 DOI: 10.1016/j.bja.2023.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 01/05/2024] Open
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
Collapse
Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Evelien Cools
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - John Fiadjoe
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Fuchs
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annery Garcia-Marcinkiewicz
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Chloe Heath
- Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia
| | - Mathias Johansen
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Jost Kaufmann
- Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany; Faculty for Health, University of Witten/Herdecke, Witten, Germany
| | - Maren Kleine-Brueggeney
- Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Pete G Kovatsis
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - James Peyton
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carolina S Romero
- Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain
| | - Britta von Ungern-Sternberg
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Arash Afshari
- Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| |
Collapse
|
4
|
Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41:3-23. [PMID: 38018248 PMCID: PMC10720842 DOI: 10.1097/eja.0000000000001928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
Collapse
Affiliation(s)
- Nicola Disma
- From the Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy (ND, AF, ACL), Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan (TA), Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (EC, WH), Medical Library, Boston Children's Hospital, Boston, MA, USA (AC), Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada (TE, MJ), Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA (JF, PGK, JP), Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AF, TR), Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA (AG-M), Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand (CH), Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia (CH, BvU-S), Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany (JK), Faculty for Health, University of Witten/Herdecke, Witten, Germany (JK), Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (MK-B), Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany (PK), Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada (CM), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (CSR), Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia (BvU-S), Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia (BvU-S), Faculty of Medicine, UCLouvain, Brussels, Belgium (FV), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark (AA)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Maroni A, Aubelle MS, Chollat C. Fetal, Preterm, and Term Neonate Exposure to Remifentanil: A Systematic Review of Efficacy and Safety. Paediatr Drugs 2023; 25:537-555. [PMID: 37541994 DOI: 10.1007/s40272-023-00583-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Owing to its pharmacodynamic properties, especially the rapid onset and short duration of its action, the use of remifentanil in obstetric anesthesia, as well as in neonatology, might be increasingly used. OBJECTIVE We conducted a systematic review to assess the efficacy and safety of remifentanil in preterm and term neonates. Outcomes of interest were neonatal adaptation after fetal exposure; neonatal pain, distress, and discomfort control during invasive procedures; and the occurrence of hemodynamic effects or respiratory depression induced by remifentanil infusion. METHODS Given the different contexts of use, we have organized this work into three parts: (A) use of remifentanil for labor or cesarean section, with exposure of the fetus before birth, (B) brief use for neonatal procedural analgesia, and (C) prolonged use for sedation/analgesia of neonates. The bibliographic search was conducted based on keywords using electronic medical databases (DATABASE, Cochrane Library, PubMed, and EMBASE) from 1 January 2000 until 31 December 2022. RESULTS Twenty-two articles were included (10 in part A, 5 in part B and 7 in part C). Prospective, controlled, randomized, blinded, and intention-to-treat trials were retained. Neonates were well adapted after exposure to remifentanil in the fetal period. Pain, stress, and discomfort were controlled during a brief or prolonged invasive procedure when remifentanil was used for sedation/analgesia. The physiological parameters were stable and the procedures were straightforward. Chest wall rigidity appeared to be a common side effect, but this can be managed by slow and continuous infusion and by using the minimum effective dose. CONCLUSIONS Remifentanil appears to be effective and safe in the short term in preterm and full-term neonates. However, its safety is compromised by the risk of chest wall rigidity. It should be used in appropriate neonatal units and in the presence of physicians able to monitor its side effects. Long-term outcomes have not been evaluated, to our knowledge.
Collapse
Affiliation(s)
- Arielle Maroni
- Pediatric Intensive Care Unit, Robert Debré University Hospital, APHP, 75019, Paris, France
| | | | - Clément Chollat
- Department of Neonatal Paediatrics, Trousseau Hospital, APHP, Sorbonne Université, 26 Av. du Dr Arnold Netter, 75012, Paris, France.
- Université Paris Cité, Inserm, NeuroDiderot, 75019, Paris, France.
| |
Collapse
|
6
|
Riva T, Engelhardt T, Basciani R, Bonfiglio R, Cools E, Fuchs A, Garcia-Marcinkiewicz AG, Greif R, Habre W, Huber M, Petre MA, von Ungern-Sternberg BS, Sommerfield D, Theiler L, Disma N. Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:101-111. [PMID: 36436541 DOI: 10.1016/s2352-4642(22)00313-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/14/2022] [Accepted: 10/14/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tracheal intubation in neonates and infants is a potentially life-saving procedure. Video laryngoscopy has been found to improve first-attempt tracheal intubation success and reduce complications compared with direct laryngoscopy in children younger than 12 months. Supplemental periprocedural oxygen might increase the likelihood of successful first-attempt intubation because of an increase in safe apnoea time. We tested the hypothesis that direct laryngoscopy is not inferior to video laryngoscopy when using standard blades and supplemental oxygen is provided. METHODS We did a non-inferiority, international, multicentre, single-blinded, randomised controlled trial, in which we randomly assigned neonates and infants aged up to 52 weeks postmenstrual age scheduled for elective tracheal intubation to either direct laryngoscopy or video laryngoscopy (1:1 ratio, randomly assigned using a secure online service) at seven tertiary paediatric hospitals across Australia, Canada, Italy, Switzerland, and the USA. An expected difficult intubation was the main exclusion criteria. Parents and patients were masked to the assigned group of treatment. All infants received supplemental oxygen (1 L/Kg per min) during laryngoscopy until the correct tracheal tube position was confirmed. The primary outcome was the proportion of first-attempt tracheal intubation success, defined as appearance of end-tidal CO2 curve at the anaesthesia monitor, between the two groups in the modified intention-to-treat analysis. A 10% non-inferiority margin between direct laryngoscopy or video laryngoscopy was applied. The trial is registered with ClinicalTrials.gov (NCT04295902) and is now concluded. FINDINGS Of 599 patients assessed, 250 patients were included between Oct 26, 2020, and March 11, 2022. 244 patients were included in the final modified intention-to-treat analysis. The median postmenstrual age on the day of intubation was 44·0 weeks (IQR 41·0-48·0) in the direct laryngoscopy group and 46·0 weeks (42·0-49·0) in the video laryngoscopy group, 34 (28%) were female in the direct laryngoscopy group and 38 (31%) were female in the video laryngoscopy group. First-attempt tracheal intubation success rate with no desaturation was higher with video laryngoscopy (89·3% [95% CI 83·7 to 94·8]; n=108/121) compared with direct laryngoscopy (78·9% [71·6 to 86·1]; n=97/123), with an adjusted absolute risk difference of 9·5% (0·8 to 18·1; p=0·033). The incidence of adverse events between the two groups was similar (-2·5% [95% CI -9·6 to 4·6]; p=0·490). Post-anaesthesia complications occurred seven times in six patients with no difference between the groups. INTERPRETATION Video laryngoscopy with standard blades in combination with supplemental oxygen in neonates and infants might increase the success rate of first-attempt tracheal intubation, when compared with direct laryngoscopy with supplemental oxygen. The incidence of hypoxaemia increased with the number of attempts, but was similar between video laryngoscopy and direct laryngoscopy. Video laryngoscopy with oxygen should be considered as the technique of choice when neonates and infants are intubated. FUNDING Swiss Pediatric Anaesthesia Society, Swiss Society for Anaesthesia and Perioperative Medicine, Foundation for Research in Anaesthesiology and Intensive Care Medicine, Channel 7 Telethon Trust, Stan Perron Charitable Foundation, National Health and Medical Research Council.
Collapse
Affiliation(s)
- Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Reto Basciani
- Department of Anaesthesiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Rachele Bonfiglio
- Unit for Research in Anaesthesia, Department of Paediatric Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Evelien Cools
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annery G Garcia-Marcinkiewicz
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert Greif
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Walid Habre
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria-Alexandra Petre
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, Australia; Perioperative Medicine Team, Telethon Kids Institute, Perth, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, Australia; Perioperative Medicine Team, Telethon Kids Institute, Perth, Australia
| | - Lorenz Theiler
- Department of Anaesthesiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Nicola Disma
- Unit for Research in Anaesthesia, Department of Paediatric Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy.
| |
Collapse
|
7
|
Tauzin M, Gouyon B, Hirt D, Carbajal R, Gouyon JB, Brunet AC, Ortala M, Goro S, Jung C, Durrmeyer X. Frequencies, Modalities, Doses and Duration of Computerized Prescriptions for Sedative, Analgesic, Anesthetic and Paralytic Drugs in Neonates Requiring Intensive Care: A Prospective Pharmacoepidemiologic Cohort Study in 30 French NICUs From 2014 to 2020. Front Pharmacol 2022; 13:939869. [PMID: 35924063 PMCID: PMC9341520 DOI: 10.3389/fphar.2022.939869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: No consensus exists about the doses of analgesics, sedatives, anesthetics, and paralytics used in critically ill neonates. Large-scale, detailed pharmacoepidemiologic studies of prescription practices are a prerequisite to future research. This study aimed to describe the detailed prescriptions of these drug classes in neonates hospitalized in neonatal intensive care units (NICU) from computerized prescription records and to compare prescriptions by gestational age. Materials and Methods: We included all neonates requiring intensive care in 30 French level III units from 2014 through 2020 with a computerized prescription for an analgesic, sedative, anesthetic, or paralytic agent. We described frequencies of prescription, methods of administration, concomitant drug prescriptions, and dosing regimen, and compared them across gestational ages. Results: Among 65,555 neonates, 29,340 (44.8%) were prescribed at least one analgesic (acetaminophen in 37.2% and opioids in 17.8%), sedative (9.8%), anesthetic (8.5%), and/or paralytic agent (1%). Among preterm infants born before 28 weeks, 3,771/4,283 (88.0%) were prescribed at least one of these agents: 69.7% opioids, 41.2% sedatives, 32.5% anesthetics, and 5.8% paralytics. The most frequently prescribed agents were sufentanil (in 10.3% of neonates) and morphine (in 8.0% of neonates) for opioids, midazolam (9.3%) for sedatives, ketamine (5.7%) and propofol (3.3%) for anesthetics. In most neonates, opioids and sedatives were prescribed as continuous infusion, whereas anesthetics were prescribed as single doses. Opioids, sedatives and paralytics were mostly prescribed in association with another agent. Doses varied significantly by gestational age but within a limited range. Gestational age was inversely related to the frequency, cumulative dose and duration of prescriptions. For example, morphine prescriptions showed median (IQR) cumulative doses of 2601 (848-6750) vs. 934 (434-2679) µg/kg and median (IQR) durations of 7 (3-15) vs. 3 (2-5) days in infants born <28 vs. ≥ 37 weeks of gestation, respectively (p-value<0.001). Conclusion: The prescriptions of analgesic, sedative, anesthetic, or paralytic agent were frequent and often combined in the NICU. Lower gestational age was associated with higher frequencies, longer durations and higher cumulative doses of these prescriptions. Dose-finding studies to determine individualized dosing regimens and studies on long-term neurodevelopmental outcome according to received cumulative doses are required.
Collapse
Affiliation(s)
- Manon Tauzin
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France
| | - Béatrice Gouyon
- Centre d’Etudes Périnatales de L’Océan Indien (CEPOI, EA7388), Université de La Réunion, Saint Pierre, France
| | - Déborah Hirt
- Pharmacology Department, Hôpital Cochin APHP, Paris, France
| | - Ricardo Carbajal
- Pediatric Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Armand Trousseau- Sorbonne Université, Paris, France
- Institut National de La Santé et de La Recherche Médicale UMR1153, Paris, France
| | - Jean-Bernard Gouyon
- Centre d’Etudes Périnatales de L’Océan Indien (CEPOI, EA7388), Université de La Réunion, Saint Pierre, France
| | | | | | - Seydou Goro
- Clinical Research Center, CHI Créteil, Créteil, France
| | - Camille Jung
- Clinical Research Center, CHI Créteil, Créteil, France
| | - Xavier Durrmeyer
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France
- Faculté de Médecine de Créteil, IMRB, GRC CARMAS, Université Paris Est Créteil, Créteil, France
| |
Collapse
|
8
|
Abstract
Chronic pain and agitation in neonatal life impact the developing brain. Oral sweet-tasting solutions should be used judiciously to mitigate behavioral responses to mild painful procedures, keeping in mind that the long-term impact is unknown. Rapidly acting opioids should be used as part of premedication cocktails for nonemergent endotracheal intubations. Continuous low-dose morphine or dexmedetomidine may be considered for preterm or term neonates exhibiting signs of stress during mechanical ventilation and therapeutic hypothermia, respectively. Further research is required regarding the pharmacokinetics, pharmacodynamics, safety, and efficacy of pharmacologic agents used to mitigate mild, moderate, and chronic pain and stress in neonates.
Collapse
Affiliation(s)
- Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110, USA; Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, F605B, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver BC V5Z 4H4, Canada
| |
Collapse
|
9
|
Durrmeyer X, Walter-Nicolet E, Chollat C, Chabernaud JL, Barois J, Chary Tardy AC, Berenguer D, Bedu A, Zayat N, Roué JM, Beissel A, Bellanger C, Desenfants A, Boukhris R, Loose A, Massudom Tagny C, Chevallier M, Milesi C, Tauzin M. Premedication before laryngoscopy in neonates: Evidence-based statement from the French society of neonatology (SFN). Front Pediatr 2022; 10:1075184. [PMID: 36683794 PMCID: PMC9846576 DOI: 10.3389/fped.2022.1075184] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/01/2022] [Indexed: 01/06/2023] Open
Abstract
CONTEXT Laryngoscopy is frequently required in neonatal intensive care. Awake laryngoscopy has deleterious effects but practice remains heterogeneous regarding premedication use. The goal of this statement was to provide evidence-based good practice guidance for clinicians regarding premedication before tracheal intubation, less invasive surfactant administration (LISA) and laryngeal mask insertion in neonates. METHODS A group of experts brought together by the French Society of Neonatology (SFN) addressed 4 fields related to premedication before upper airway access in neonates: (1) tracheal intubation; (2) less invasive surfactant administration; (3) laryngeal mask insertion; (4) use of atropine for the 3 previous procedures. Evidence was gathered and assessed on predefined questions related to these fields. Consensual statements were issued using the GRADE methodology. RESULTS Among the 15 formalized good practice statements, 2 were strong recommendations to do (Grade 1+) or not to do (Grade 1-), and 4 were discretionary recommendations to do (Grade 2+). For 9 good practice statements, the GRADE method could not be applied, resulting in an expert opinion. For tracheal intubation premedication was considered mandatory except for life-threatening situations (Grade 1+). Recommended premedications were a combination of opioid + muscle blocker (Grade 2+) or propofol in the absence of hemodynamic compromise or hypotension (Grade 2+) while the use of a sole opioid was discouraged (Grade 1-). Statements regarding other molecules before tracheal intubation were expert opinions. For LISA premedication was recommended (Grade 2+) with the use of propofol (Grade 2+). Statements regarding other molecules before LISA were expert opinions. For laryngeal mask insertion and atropine use, no specific data was found and expert opinions were provided. CONCLUSION This statement should help clinical decision regarding premedication before neonatal upper airway access and favor standardization of practices.
Collapse
Affiliation(s)
- Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Université Paris Est Créteil, Faculté de Santé de Créteil, IMRB, GRC CARMAS, Créteil, France
| | - Elizabeth Walter-Nicolet
- Neonatal Medicine and Intensive Care Unit, Saint Joseph Hospital, Paris, France.,University of Paris-Cité, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Paris, France
| | - Clément Chollat
- Department of Neonatology, Hôpital Armand Trousseau, APHP, Sorbonne Université, Paris, France
| | - Jean-Louis Chabernaud
- Division of Neonatal and Pediatric Critical Care Transportation, Hôpital Antoine Beclere, AP-HP, Paris - Saclay University Hospital, Clamart, France
| | - Juliette Barois
- Department of Neonatology and Neonatal Intensive Care, CH de Valenciennes, Valenciennes, France
| | - Anne-Cécile Chary Tardy
- Department of Neonatology and Neonatal Intensive Care, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Daniel Berenguer
- Department of Pediatric Anesthesia and Pediatric Transport (SMUR Pédiatrique), Hôpital des Enfants, CHU de Bordeaux, Bordeaux, France
| | - Antoine Bedu
- Department of Neonatal Pediatrics and Intensive Care, Limoges University Hospital, Limoges, France
| | - Noura Zayat
- Department of Neonatal Intensive Care and Pediatric Transport, CHU de Nantes, Nantes, France
| | - Jean-Michel Roué
- Department of Pediatric and Neonatal Critical Care, Brest University Hospital, Brest, France
| | - Anne Beissel
- Neonatal Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Claire Bellanger
- Department of Neonatology and Neonatal Intensive Care, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
| | - Aurélie Desenfants
- Department of Neonatology, CHU Nimes, Université Montpellier, Nimes, France
| | - Riadh Boukhris
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Loose
- Department of Neonatology, CHRU de Tours, Hôpital Bretonneau, Tours, France
| | - Clarisse Massudom Tagny
- Department of Neonatology and Neonatal Intensive Care, Grand Hôpital de L'Est Francilien, Meaux, France
| | - Marie Chevallier
- Department of Neonatal Intensive Care Unit, CHU Grenoble, Grenoble, France.,TIMC-IMAG Research Department, Grenoble Alps University, Grenoble, France
| | - Christophe Milesi
- Department of Neonatal Medicine and Pediatric Intensive Care, Montpellier University Hospital, Université de Montpellier, Montpellier, France
| | - Manon Tauzin
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| |
Collapse
|
10
|
Badr M, Goulard M, Theret B, Roubertie A, Badiou S, Pifre R, Bres V, Cambonie G. Fatal accidental lipid overdose with intravenous composite lipid emulsion in a premature newborn: a case report. BMC Pediatr 2021; 21:584. [PMID: 34930217 PMCID: PMC8686371 DOI: 10.1186/s12887-021-03064-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/08/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Tenfold or more overdose of a drug or preparation is a dreadful adverse event in neonatology, often due to an error in programming the infusion pump flow rate. Lipid overdose is exceptional in this context and has never been reported during the administration of a composite intravenous lipid emulsion (ILE). CASE PRESENTATION Twenty-four hours after birth, a 30 weeks' gestation infant with a birthweight of 930 g inadvertently received 28 ml of a composite ILE over 4 h. The ILE contained 50% medium-chain triglycerides and 50% soybean oil, corresponding to 6 g/kg of lipids (25 mg/kg/min). The patient developed acute respiratory distress with echocardiographic markers of pulmonary hypertension and was treated with inhaled nitric oxide and high-frequency oscillatory ventilation. Serum triglyceride level peaked at 51.4 g/L, 17 h after the lipid overload. Triple-volume exchange transfusion was performed twice, decreasing the triglyceride concentration to < 10 g/L. The infant's condition remained critical, with persistent bleeding and shock despite supportive treatment and peritoneal dialysis. Death occurred 69 h after the overdose in a context of refractory lactic acidosis. CONCLUSIONS Massive ILE overdose is life-threatening in the early neonatal period, particularly in premature and hypotrophic infants. This case highlights the vigilance required when ILEs are administered separately from other parenteral intakes. Exchange transfusion should be considered at the first signs of clinical or biological worsening to avoid progression to multiple organ failure.
Collapse
Affiliation(s)
- Maliha Badr
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France
| | - Marion Goulard
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France
| | - Bénédicte Theret
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France
| | - Agathe Roubertie
- Department of Neuropaediatrics, Gui de Chauliac Hospital, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Stéphanie Badiou
- Department of Biochemistry and Hormonology, Lapeyronie Hospital, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Roselyne Pifre
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France
| | - Virginie Bres
- Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Gilles Cambonie
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France
- Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France
| |
Collapse
|
11
|
Neonatal tracheal intubation: From art to evidence. Eur J Anaesthesiol 2021; 38:1109-1110. [PMID: 34617918 DOI: 10.1097/eja.0000000000001594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
12
|
Dahan S, Jung C, Dassieu G, Durrmeyer X, Caeymaex L. Trust and consent: a prospective study on parents' perspective during a neonatal trial. JOURNAL OF MEDICAL ETHICS 2021; 47:678-683. [PMID: 32079742 DOI: 10.1136/medethics-2019-105597] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 01/21/2020] [Accepted: 02/03/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE This study aimed to describe how parents and physicians experienced the informed consent interview and to investigate the aspects of the relationship that influenced parents' decision during the consent process for a randomised clinical trial in a tertiary neonatal intensive care unit (NICU). The secondary objective was to describe the perspectives of parents and physicians in the specific situation of prenatal informed consent. SETTING Single centre study in NICU of the Centre Hospitalier Intercommunal de Créteil, France, using a convenience period from February to May 2016. DESIGN Ancillary study to a randomised clinical trial: Prettineo. Records of interviews for consent. POPULATION parents and physicians. Mixed study including qualitative and quantitative interview data about participants' recall and feelings about the consent process. Interviews were reviewed using thematic discourse analysis. RESULTS Parents' recall and understanding of the study's main goal and design was good. Parents and physicians had a positive experience, and trust was one of the main reasons for parents to consent. Misunderstanding (bad comprehension) was the main reason for refusal.Before birth, three situations can compromise parents' consent: the mother already consented to participate in other studies, the absence of the father during the interview and the feeling that the baby's birth is not an imminent possibility. CONCLUSIONS Confronting parents and physicians' perspectives in research can help us reach answers to sensitive issues such as content and timing of information. Each different types of study raises different ethical dilemmas for consent that might be discussed in a more individual way.
Collapse
Affiliation(s)
- Sonia Dahan
- Neonatal intensive care unit, Centre hospitalier intercommunal de Créteil, Créteil, Ile-de-France, France
- Faculté de Médecine, Université Paris Est Créteil Val de Marne, Faculté de Médecine, Créteil, Ile-de-France, France
| | - Camille Jung
- Faculté de Médecine, Université Paris Est Créteil Val de Marne, Faculté de Médecine, Créteil, Ile-de-France, France
- Pediatrics, Centre hospitalier Intercommunal de Créteil Val-de-Marne, Creteil, Île-de-France, France
| | - Gilles Dassieu
- Neonatal intensive care unit, Centre hospitalier intercommunal de Créteil, Créteil, Ile-de-France, France
- Faculté de Médecine, Université Paris Est Créteil Val de Marne, Faculté de Médecine, Créteil, Ile-de-France, France
| | - Xavier Durrmeyer
- Neonatal intensive care unit, Centre hospitalier intercommunal de Créteil, Créteil, Ile-de-France, France
- Faculté de Médecine, Université Paris Est Créteil Val de Marne, Faculté de Médecine, Créteil, Ile-de-France, France
| | - Laurence Caeymaex
- Neonatal intensive care unit, Centre hospitalier intercommunal de Créteil, Créteil, Ile-de-France, France
- Faculté de Médecine, Université Paris Est Créteil Val de Marne, Faculté de Médecine, Créteil, Ile-de-France, France
- CEDITEC, Universite Paris-Est Creteil Val de Marne, Creteil, France
| |
Collapse
|
13
|
Walter‐Nicolet E, Marchand‐Martin L, Guellec I, Biran V, Moktari M, Zana‐Taieb E, Magny J, Desfrère L, Waszak P, Boileau P, Chauvin G, Saint Blanquat L, Borrhomée S, Droutman S, Merhi M, Zupan V, Karoui L, Cimerman P, Carbajal R, Durrmeyer X. Premedication practices for neonatal tracheal intubation: Results from the EPIPPAIN 2 prospective cohort study and comparison with EPIPPAIN 1. PAEDIATRIC AND NEONATAL PAIN 2021; 3:46-58. [PMID: 35547594 PMCID: PMC8975199 DOI: 10.1002/pne2.12048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 11/25/2022]
Abstract
To describe the frequency and nature of premedication practices for neonatal tracheal intubation (TI) in 2011; to identify independent risk factors for the absence of premedication; to compare data with those from 2005 and to confront observed practices with current recommendations. Data concerning TI performed in neonates during the first 14 days of their admission to participating neonatal/pediatric intensive care units were prospectively collected at the bedside. This study was part of the Epidemiology of Procedural Pain in Neonates study (EPIPPAIN 2) conducted in 16 tertiary care units in the region of Paris, France, in 2011. Multivariate analysis was used to identify factors associated with premedication use and multilevel analysis to identify center effect. Results were compared with those of the EPIPPAIN 1 study, conducted in 2005 with a similar design, and to a current guidance for the clinician for this procedure. One hundred and twenty‐one intubations carried out in 121 patients were analyzed. The specific premedication rate was 47% and drugs used included mainly propofol (26%), sufentanil (24%), and ketamine (12%). Three factors were associated with the use of a specific premedication: nonemergent TI (Odds ratio (OR) [95% CI]: 5.3 [1.49‐20.80]), existence of a specific written protocol in the ward (OR [95% CI]:4.80 [2.12‐11.57]), and the absence of a nonspecific concurrent analgesia infusion before TI (OR [95% CI]: 3.41 [1.46‐8.45]). No center effect was observed. The specific premedication rate was lower than the 56% rate observed in 2005. The drugs used were more homogenous and consistent with the current recommendations than in 2005, especially in centers with a specific written protocol. Premedication use prior to neonatal TI was low, even for nonemergent procedures. Scientific consensus, implementation of international or national recommendations, and local written protocols are urgently needed to improve premedication practices for neonatal intubation.
Collapse
Affiliation(s)
- Elizabeth Walter‐Nicolet
- Medicine and Neonatal Intensive Care Unit Saint Joseph Hospital Paris France
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
| | - Laetitia Marchand‐Martin
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
| | - Isabelle Guellec
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Paediatric and Neonatal Intensive Care Unit, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
- Medicine Sorbonne University Paris France
| | - Valérie Biran
- Neonatal Intensive Care Unit Assistance Publique – Hôpitaux de Paris CHU Robert Debré University Paris Diderot, Sorbonne Paris Cité Paris France
- Inserm U1141 University Paris Diderot, Sorbonne Paris Cité Paris France
| | - Mostafa Moktari
- Pediatric and Neonatal Intensive Care Unit Bicêtre Hospital Assistance Publique – Hôpitaux de Paris Paris France
- Espace Ethique/Ile de France ‐ Saint‐Louis Hospital Assistance Publique ‐Hôpitaux de Paris Paris France
| | - Elodie Zana‐Taieb
- Port‐Royal Maternity Neonatal Intensive Care Unit Cochin‐Port Royal Hospital Assistance Publique‐Hôpitaux de Paris Paris France
| | - Jean‐François Magny
- Neonatal Intensive Care Unit Necker‐Enfants Maladies Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Luc Desfrère
- Neonatal Intensive Care Unit Louis Mourier Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Paul Waszak
- Medicine and Neonatal Intensive Care Unit Delafontaine Hospital Saint Denis France
| | - Pascal Boileau
- Neonatal Intensive Care Unit Centre Hospitalier Intercommunal Poissy‐Saint Germain Poissy France
- Inserm U1185 Université Paris Saclay Le Kremlin‐Bicêtre France
| | - Gilles Chauvin
- Neonatal Intensive Care Unit Argenteuil Hospital Argenteuil France
| | - Laure Saint Blanquat
- Pediatric and Neonatal Intensive Care Unit Necker‐enfants Malades Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | | | - Stéphanie Droutman
- Pediatric and Neonatal Intensive Care Unit Centre Hospitalier Intercommunal André Grégoire Montreuil France
| | - Mona Merhi
- Neonatal Intensive Care Unit Centre Hospitalier Sud Francilien Corbeil‐Essonnes France
| | - Véronique Zupan
- Neonatal Intensive Care Unit Antoine Béclère Hospital Assistance Publique – Hôpitaux de Paris Clamart France
| | - Leila Karoui
- Neonatal Intensive Care Unit, Grand hôpital de l’Est francilien, site de Meaux Meaux France
| | - Patricia Cimerman
- Centre National de Ressources de lutte contre la Douleur, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Ricardo Carbajal
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Medicine Sorbonne University Paris France
- Paediatric Emergency Department, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Xavier Durrmeyer
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Neonatal Intensive Care Unit Centre Hospitalier Intercommunal de Créteil University Paris Est Créteil Créteil France
- Faculté de Médecine de Créteil IMRB, GRC CARMAS Université Paris Est Créteil Créteil France
| |
Collapse
|
14
|
Neurodevelopmental Outcomes after Premedication with Atropine/Propofol vs Atropine/Atracurium/Sufentanil for Neonatal Intubation: 2-Year Follow-Up of a Randomized Clinical Trial. J Pediatr 2021; 231:273-277.e3. [PMID: 33301785 DOI: 10.1016/j.jpeds.2020.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/28/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023]
Abstract
This study followed 173 newborn infants in the PREmedication Trial for Tracheal Intubation of the NEOnate multicenter, double-blind, randomized controlled trial of atropine-propofol vs atropine-atracurium-sufentanil for premedication before nonemergency intubation. At 2 years of corrected age, there was no significant difference between the groups in death or risk of neurodevelopmental delay assessed with the Ages and Stages Questionnaire. Trial registration Clinicaltrials.gov: NCT01490580.
Collapse
|
15
|
Disma N, Virag K, Riva T, Kaufmann J, Engelhardt T, Habre W. Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study. Br J Anaesth 2021; 126:1173-1181. [PMID: 33812665 DOI: 10.1016/j.bja.2021.02.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. METHODS We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. RESULTS Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1-6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2<90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. CONCLUSIONS The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event. CLINICAL TRIAL REGISTRATION NCT02350348.
Collapse
Affiliation(s)
- Nicola Disma
- Unit for Research & Innovation in Anaesthesia, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy.
| | - Katalin Virag
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Thomas Riva
- Department of Anaesthesiology and Pain Therapy, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jost Kaufmann
- Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany; Faculty for Health, University of Witten/Herdecke, Witten, Germany
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Walid Habre
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Kort EHM, Twisk JWR, t Verlaat EPG, Reiss IKM, Simons SHP, Weissenbruch MM. Propofol in neonates causes a dose-dependent profound and protracted decrease in blood pressure. Acta Paediatr 2020; 109:2539-2546. [PMID: 32248549 PMCID: PMC7754147 DOI: 10.1111/apa.15282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 12/01/2022]
Abstract
AIM To analyse the effects of different propofol starting doses as premedication for endotracheal intubation on blood pressure in neonates. METHODS Neonates who received propofol starting doses of 1.0 mg/kg (n = 30), 1.5 mg/kg (n = 23) or 2.0 mg/kg (n = 26) as part of a previously published dose-finding study were included in this analysis. Blood pressure in the 3 dosing groups was analysed in the first 60 minutes after start of propofol. RESULTS Blood pressure declined after the start of propofol in all 3 dosing groups and was not restored 60 minutes after the start of propofol. The decline in blood pressure was highest in the 2.0 mg/kg dosing group. Blood pressure decline was mainly dependent on the initial propofol starting dose rather than the cumulative propofol dose. CONCLUSION Propofol causes a dose-dependent profound and prolonged decrease in blood pressure. The use of propofol should be carefully considered. When using propofol, starting with a low dose and titrating according to sedative effect seems the safest strategy.
Collapse
Affiliation(s)
- Ellen H. M. Kort
- Division of Neonatology Department of Pediatrics Máxima Medical Center Veldhoven The Netherlands
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Jos W. R. Twisk
- Department of Epidemiology and Biostatistics Amsterdam UMC Location VU University Medical Center Amsterdam The Netherlands
| | - Ellen P. G. t Verlaat
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Irwin K. M. Reiss
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Sinno H. P. Simons
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Mirjam M. Weissenbruch
- Division of Neonatology Department of Pediatrics Amsterdam UMC Location VU University Medical Center Amsterdam The Netherlands
| |
Collapse
|
17
|
de Kort EH, Prins SA, Reiss IK, Willemsen SP, Andriessen P, van Weissenbruch MM, Simons SH. Propofol for endotracheal intubation in neonates: a dose-finding trial. Arch Dis Child Fetal Neonatal Ed 2020; 105:489-495. [PMID: 31932363 PMCID: PMC7547906 DOI: 10.1136/archdischild-2019-318474] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/21/2019] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To find propofol doses providing effective sedation without side effects in neonates of different gestational ages (GA) and postnatal ages (PNA). DESIGN AND SETTING Prospective multicentere dose-finding study in 3 neonatal intensive care units. PATIENTS Neonates with a PNA <28 days requiring non-emergency endotracheal intubation. INTERVENTIONS Neonates were stratified into 8 groups based on GA and PNA. The first 5 neonates in every group received a dose of 1.0 mg/kg propofol. Based on sedative effect and side effects, the dose was increased or decreased in the next 5 patients until the optimal dose was found. MAIN OUTCOME MEASURES The primary outcome was the optimal single propofol starting dose that provides effective sedation without side effects in each age group. RESULTS After inclusion of 91 patients, the study was prematurely terminated because the primary outcome was only reached in 13% of patients. Dose-finding was completed in 2 groups, but no optimal propofol dose was found. Effective sedation without side effects was achieved more often after a starting dose of 2.0 mg/kg (28%) than after 1.0 mg/kg (3%) and 1.5 mg/kg (9%). Propofol-induced hypotension occurred in 59% of patients. Logistic regression analyses showed that GA and PNA did not predict effective sedation or the occurrence of hypotension. CONCLUSIONS Effective sedation without side effects is difficult to achieve with propofol and the optimal dose in different age groups of neonates could not be determined. The sedative effect of propofol and the occurrence of hypotension are unpredictable and show large inter-individual variability in the neonatal population.
Collapse
Affiliation(s)
- Ellen H.M. de Kort
- Neonatology, Maxima Medical Center, Veldhoven, The Netherlands,Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sandra A. Prins
- Neonatology, Amsterdam UMC location VU Medical Center, Amsterdam, The Netherlands
| | - Irwin K.M. Reiss
- Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | | | | | - Sinno H.P. Simons
- Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
18
|
Balakrishnan A, Sanghera RS, Boyle EM. New techniques, new challenges—The dilemma of pain management for less invasive surfactant administration? PAEDIATRIC AND NEONATAL PAIN 2020; 3:2-8. [PMID: 35548851 PMCID: PMC8975189 DOI: 10.1002/pne2.12033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 06/01/2020] [Accepted: 06/09/2020] [Indexed: 12/18/2022]
Abstract
Recent years have seen the increasing use of noninvasive respiratory support in preterm infants with the aim of minimizing the risk of mechanical ventilation and subsequent bronchopulmonary dysplasia. Respiratory distress syndrome is the most common respiratory diagnosis in preterm infants, and is best treated by administration of surfactant. Until recently, this has been performed via an endotracheal tube using premedication, which has often included opiate analgesia; subsequently, the infant has been ventilated. Avoidance of mechanical ventilation, however, does not negate the need for surfactant therapy. Less invasive surfactant administration (LISA) in spontaneously breathing infants is increasing in popularity, and appears to have beneficial effects. However, laryngoscopy is necessary, which carries adverse effects and is painful for the infant. Conventional methods of premedication for intubation tend to reduce respiratory drive, which increases the likelihood of ventilation being required. This has led to intense debate about the best strategy for providing appropriate treatment, taking into account both the respiratory needs of the infant and the need to alleviate procedural pain. Currently, clinical practice varies considerably and there is no consensus with respect to optimal management. This review seeks to summarize the benefits, risks, and challenges associated with this new approach.
Collapse
Affiliation(s)
| | | | - Elaine M. Boyle
- Department of Health Sciences University of Leicester Leicester UK
| |
Collapse
|
19
|
Mari J, Franczia P, Margas W, Rutkowski J, Bebrysz M, Bokiniec R, Seliga‐Siwecka J. International consensus is needed on premedication for non-emergency neonatal intubation after survey found wide-ranging policies and practices in 70 countries. Acta Paediatr 2020; 109:1369-1375. [PMID: 31797442 DOI: 10.1111/apa.15119] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/01/2019] [Accepted: 12/02/2019] [Indexed: 12/25/2022]
Abstract
AIM This study evaluated whether practitioners from 70 countries used premedication for non-emergency neonatal intubation and identified attitudes and experience regarding the safety, side effects and efficiency of neonatal intubation. METHODS Invitations to take part in the survey were issued between December 18, 2018 and February 4, 2019 to the users of neonatal-based websites and Facebook groups, members of professional societies and the authors of relevant publications in the last five years. RESULTS We analysed 718 completed questionnaires from 40 European and 30 non-European countries. Most of the responses were from neonatologists (69.6%) and paediatric or neonatal trainees (10.3%). In units without a protocol (31.6%), more than half of the practitioners (60.4%) chose premedication according to personal preference and 37.0%-11.9% of the overall respondents did not use any drugs for non-emergency intubation. The most frequently reported drug combination was fentanyl, atropine and succinylcholine (6.8%). Most of the practitioners (78.5%) use the same drugs for term and preterm infants. Only 24.8% of the physicians were fully satisfied with their premedication practices. CONCLUSION Nearly 12% of the respondents did not use premedication for non-emergency neonatal intubation. The wide-ranging policies and practices found among the respondents highlight the need for international consensus guidelines.
Collapse
Affiliation(s)
- Judit Mari
- Paediatric Department University of Szeged Szeged Hungary
| | | | | | | | | | - Renata Bokiniec
- Department of Neonatology and Neonatal intensive Care Medical University of Warsaw Warsaw Poland
| | - Joanna Seliga‐Siwecka
- Department of Neonatology and Neonatal intensive Care Medical University of Warsaw Warsaw Poland
| |
Collapse
|
20
|
Chevallier M, Durrmeyer X, Ego A, Debillon T. Propofol versus placebo (with rescue with ketamine) before less invasive surfactant administration: study protocol for a multicenter, double-blind, placebo controlled trial (PROLISA). BMC Pediatr 2020; 20:199. [PMID: 32384914 PMCID: PMC7206779 DOI: 10.1186/s12887-020-02112-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/29/2020] [Indexed: 01/05/2023] Open
Abstract
Background One major limitation for less invasive surfactant administration (LISA) is the difficulty in providing sedation before this procedure and the competitive risk of respiratory depression versus avoidance of intubation for most sedative or analgesic drugs used in this context. The objective of this study is to compare the need for mechanical ventilation within 72 h of life following premedication with propofol, versus placebo (rescue with ketamine), for the LISA procedure in preterm neonates born before 32 weeks gestational age (wGA). Methods ProLISA is a phase III, non-inferiority, multicenter, double blind, randomized, placebo controlled trial designed according to the SPIRIT Statement. Neonates born before 32 wGA in 12 geographically dispersed Neonatal Intensive Care Units in France needing surfactant will be included from September 2019 to September 2022. A sample of 542 patients is needed. The neonate is randomized to the intervention (propofol) or control placebo group. Open label rescue treatment with ketamine is possible in both groups if FANS (Faceless Acute Neonatal pain Scale) is ≥6. To guide drug administration, FANS is scored before attempting laryngoscopy. Once an adequate score has been obtained, LISA is performed according to a standardized protocol. The primary outcome is the need for mechanical ventilation within 72 h of life. Secondary outcomes are tolerance of the procedure, pain evaluation, hemodynamic and neurologic parameters after the intervention, morbidities before discharge and neurodevelopmental assessment at 2 years of age. Discussion This paper describes the first multicenter, double-blind, randomized, placebo-controlled trial on this topic and will provide crucial information to support implementation of the LISA procedure. Trial registration ClinicalTrials.gov: NCT04016246. Registered 06 June 2019, N°EUDRACT: 2018–002876-41.
Collapse
Affiliation(s)
- Marie Chevallier
- UMR 5525 ThEMAS, CNRS, TIMC-IMAG, Grenoble Alps University, Grenoble, France. .,Neonatal Intensive Care Unit, Grenoble Alps University Hospital, Grenoble, France.
| | - Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Université Paris Est, IMRB- GRC GEMINI, Créteil, France.,Inserm, U1153, Obstetrical, Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne, Paris Descartes University, Paris, France
| | - Anne Ego
- Neonatal Intensive Care Unit, Grenoble Alps University Hospital, Grenoble, France
| | - Thierry Debillon
- UMR 5525 ThEMAS, CNRS, TIMC-IMAG, Grenoble Alps University, Grenoble, France.,Neonatal Intensive Care Unit, Grenoble Alps University Hospital, Grenoble, France
| | | |
Collapse
|
21
|
Mekitarian Filho E, Riechelmann MB. Propofol use in newborns and children: is it safe? A systematic review. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
22
|
Filho EM, Riechelmann MB. Propofol use in newborns and children: is it safe? A systematic review. J Pediatr (Rio J) 2020; 96:289-309. [PMID: 31926134 PMCID: PMC9432291 DOI: 10.1016/j.jped.2019.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/26/2019] [Accepted: 07/26/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To determine the main indications and assess the most common adverse events with the administration of hypnotic propofol in most pediatric clinical scenarios. SOURCES A systematic review of PubMed, SciELO, Cochrane, and EMBASE was performed, using filters such as a maximum of five years post-publication, and/or references or articles of importance, with emphasis on clinical trials using propofol. All articles of major relevance were blind-reviewed by both authors according to the PRISMA statement, looking for possible bias and limitations or the quality of the articles. SUMMARY OF THE FINDINGS Through the search criterion applied, 417 articles were found, and their abstracts evaluated. A total of 69 papers were thoroughly studied. Articles about propofol use in children are increasing, including in neonates, with the majority being cohort studies and clinical trials in two main scenarios: upper digestive endoscopy and magnetic resonance imaging. A huge list of adverse events has been published, but most articles considered them of low risk. CONCLUSIONS Propofol is a hypnotic drug with a safe profile of efficacy and adverse events. Indeed, when administered by non-anesthesiologists, quick access to emergency care must be provided, especially in airway events. The use of propofol in other scenarios must be better studied, aiming to reduce the limitations of its administration by general pediatricians.
Collapse
Affiliation(s)
- Eduardo Mekitarian Filho
- Universidade de São Paulo (USP), Faculdade de Medicina, São Paulo, SP, Brazil; Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil; Universidade Cidade de São Paulo (Unicid), Faculdade de Medicina, São Paulo, SP, Brazil; Hospital Santa Catarina, São Paulo, SP, Brazil.
| | | |
Collapse
|
23
|
Truong L, Kim JH, Katheria AC, Finer NN, Marc-Aurele K. Haemodynamic effects of premedication for neonatal intubation: an observational study. Arch Dis Child Fetal Neonatal Ed 2020; 105:123-127. [PMID: 31036701 DOI: 10.1136/archdischild-2018-316235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine changes in blood pressure (BP), cardiac output (CO) and cerebral regional oxygen saturation (rScO2) with administration of premedication for neonatal intubation. DESIGN Pilot, prospective, observational study. Oxygen saturation, heart rate, CO, rScO2 and BP data were collected. Monitoring began 5 min prior to premedication and continued until spontaneous movement. SETTING Single-centre, level 3 neonatal intensive care unit PATIENTS: 35 infants, all gestational ages. 81 eligible infants: 66 consented, 15 refused. INTERVENTIONS Intravenous atropine, fentanyl or morphine, ±cisatracurium MAIN OUTCOME MEASURES: BP, CO, rScO2 RESULTS: n=37 intubations. Mean gestational age and median birth weight were 31 4/7 weeks and 1511 g. After premedication, 10 episodes resulted in a BP increase from baseline and 27 in a BP decrease. Of those whose BP decreased, 17 had <20% decrease and 10 had ≥20% decrease. Those with <20% BP decrease took an average of 2.5 min to return to baseline while those with a ≥20% BP decline took an average of 15.2 min. Three did not return to baseline by 35 min. Following intubation, further declines in BP (21%-51%) were observed in eight additional cases. One infant required a bolus for persistently low BPs. CO and rScO2 changes were statistically similar between the two groups. CONCLUSION About 30% of infants dropped their BP by ≥20% after premedication for elective intubation. These BP changes were not associated with any significant change in rScO2 or CO. More data are needed to better characterise the immediate haemodynamic changes and clinical outcomes associated with premedication.
Collapse
Affiliation(s)
- Linda Truong
- Department of Pediatrics, Division of Neonatal-Developmental Medicine, Stanford University, Palo Alto, California, USA
| | - Jae H Kim
- Department of Pediatrics, Division of Neonatology, University of California San Diego Health System, San Diego, California, USA.,Department of Pediatrics, Division of Neonatology, Rady Children's Hospital of San Diego, San Diego, California, USA
| | | | - Neil N Finer
- Department of Pediatrics, Division of Neonatology, University of California San Diego Health System, San Diego, California, USA
| | - Krishelle Marc-Aurele
- Department of Pediatrics, Division of Neonatology, University of California San Diego Health System, San Diego, California, USA.,Department of Pediatrics, Division of Neonatology, Rady Children's Hospital of San Diego, San Diego, California, USA
| |
Collapse
|
24
|
de Kort E, Kusters S, Niemarkt H, van Pul C, Reiss I, Simons S, Andriessen P. Quality assessment and response to less invasive surfactant administration (LISA) without sedation. Pediatr Res 2020; 87:125-130. [PMID: 31450233 PMCID: PMC7223491 DOI: 10.1038/s41390-019-0552-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/24/2019] [Accepted: 08/16/2019] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although sedative premedication for endotracheal intubation is considered standard of care, less invasive surfactant administration (LISA) is often performed without sedative premedication. The aim of this study was to assess success rates, technical quality and vital parameters in LISA without sedative premedication. METHODS Prospective observational study in 86 neonates <32 weeks' gestation. LISA was performed according to a standardized protocol without use of sedative premedication. Outcome measures were success rates of LISA attempts, reasons for failure and quality of technical conditions. In 37 neonates, heart rate and oxygen saturation levels from 20 min before until 30 min after start of LISA were collected. RESULTS In 48% of LISAs the first attempt failed and in 34% quality of technical conditions was inadequate. The success rate was significantly correlated with quality of technical conditions and experience of the performer. Desaturations <80% occurred in 54% of patients while bradycardia <80/min did not occur. CONCLUSION This study shows a relatively low success rate of the first attempt of LISA, frequent inadequacy of technical quality and frequent oxygen desaturations. These effects may be improved by the use of sedative premedication.
Collapse
Affiliation(s)
- Ellen de Kort
- Division of Neonatology, Department of Pediatrics, Máxima Medical Center, Veldhoven, the Netherlands.
- Division of Neonatology, Department of Pediatrics, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Suzanne Kusters
- Human & Technology, Biometrics, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Hendrik Niemarkt
- Division of Neonatology, Department of Pediatrics, Máxima Medical Center, Veldhoven, the Netherlands
| | - Carola van Pul
- Department of Clinical Physics, Máxima Medical Center, Veldhoven, the Netherlands
| | - Irwin Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sinno Simons
- Division of Neonatology, Department of Pediatrics, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Peter Andriessen
- Division of Neonatology, Department of Pediatrics, Máxima Medical Center, Veldhoven, the Netherlands
| |
Collapse
|
25
|
Carbajal R, Lode N, Ayachi A, Chouakri O, Henry-Larzul V, Kessous K, Normand A, Courtois E, Rousseau J, Cimerman P, Chabernaud JL. Premedication practices for tracheal intubation in neonates transported by French medical transport teams: a prospective observational study. BMJ Open 2019; 9:e034052. [PMID: 31727669 PMCID: PMC6886912 DOI: 10.1136/bmjopen-2019-034052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Premedication practices for neonatal tracheal intubations have not yet been described for neonatal transport teams. Our objective is to describe the use of sedation/analgesia (SA) for tracheal intubations and to assess its tolerance in neonates transported by medical transport teams in France. SETTING This prospective observational study was part of the EPIPPAIN 2 project and collected around-the-clock data on SA practices in neonates intubated by all five paediatric medical transport teams of the Paris region during a 2-month period. Intubations were classified as emergent, semiemergent and non-emergent. Sedation level and conditions of intubation were assessed with the Tonus, Reactivity, Awareness and Conditions of intubation to Help in Endotracheal intubation Assessment (TRACHEA score). The scores range from 0 to 10 representing an increasing ladder from adequate to inadequate sedation, and from excellent to very poor conditions of intubation. PARTICIPANTS 40 neonates intubated in 28 different centres. RESULTS The mean (SD) age was 34.9 (3.9) weeks, and 62.5% were intubated in the delivery room. 30/40 (75%) of intubations were performed with the use of SA. In 18/30 (60.0%) intubations performed with SA, the drug regimen was the association of sufentanil and midazolam. Atropine was given in 19/40 intubations. From the 16, 21 and 3 intubations classified as emergent, semiemergent and non-emergent, respectively, 8 (50%), 19 (90.5%) and 3 (100%) were performed with SA premedication. 79.3% of intubations performed with SA had TRACHEA scores of 3 or less. 22/40 (55%) infants had at least one of the following adverse events: muscle rigidity, bradycardia below 100/min, desaturation below 80% and nose or pharynx-larynx bleeding. 7/24 (29.2%) of those who had only one attempt presented at least one of these adverse events compared with 15/16 (93.8%) of those who needed two or more attempts (p<0.001). CONCLUSION SA premedication is largely feasible for tracheal intubations performed in neonates transported by medical transport teams including intubations judged as emergent or semiemergent. TRIAL REGISTRATION NUMBER NCT01346813; Results.
Collapse
Affiliation(s)
- Ricardo Carbajal
- Service des Urgences Pédiatriques, Hôpital Trousseau, Paris, France
- Médecine Sorbonne Université, INSERM UMR 1153 Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France
| | - Noella Lode
- Neonatal Transport Team, SMUR Pédiatrique, Hôpital Robert Debré, SAMU de Paris (AP-HP), Paris, France
| | - Azzedine Ayachi
- Neonatal Transport Team, SMUR Pédiatrique, SAMU de Seine Saint Denis (AP-HP), Montreuil, France
| | - Ourida Chouakri
- Neonatal Transport Team, SMUR Pédiatrique Necker, Hôpital Necker, SAMU de Paris (AP-HP), Paris, France
| | | | - Katia Kessous
- Neonatal Transport Team, SMUR Pédiatrique, Hôpital Robert Debré, SAMU de Paris (AP-HP), Paris, France
| | - Audrey Normand
- Neonatal Transport Team, SMUR Pédiatrique, Hôpital Antoine Béclère, SAMU des Hauts de Seine, Hôpitaux Universitaires Paris-Sud (AP-HP), Clamart, Hauts de Seine, France
| | - Emilie Courtois
- Paediatric Emergency Department, Assitance Publique-Hôpitaux de Paris, Paris, France
| | - Jessica Rousseau
- INSERM UMR 1153 Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France
| | - Patricia Cimerman
- Centre National de Ressources de Lutte Contre la Douleur, Hopital Armand Trousseau, Paris, France
| | - Jean-Louis Chabernaud
- Neonatal Transport Team, SMUR Pédiatrique, Hôpital Antoine Béclère, SAMU des Hauts de Seine, Hôpitaux Universitaires Paris-Sud (AP-HP), Clamart, Hauts de Seine, France
| |
Collapse
|
26
|
Vedrenne-Cloquet M, Breinig S, Dechartres A, Jung C, Renolleau S, Marchand-Martin L, Durrmeyer X. Cerebral Oxygenation During Neonatal Intubation-Ancillary Study of the Prettineo-Study. Front Pediatr 2019; 7:40. [PMID: 30881948 PMCID: PMC6407664 DOI: 10.3389/fped.2019.00040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/30/2019] [Indexed: 01/25/2023] Open
Abstract
Purpose: This study aimed to describe cerebral Near InfraRed Spectroscopy (NIRS) profiles during neonatal intubation using two different premedication regimens. Methods: Neonates requiring non-emergency intubation were enrolled in an ancillary study, conducted in two French Neonatal Intensive Care Units participating in a larger on-going multicenter, double blind, randomized, controlled trial. Patients were randomly assigned to the "atropine-propofol" (Prop) group or the "atropine-atracurium-sufentanil" (SufTrac) group. Regional cerebral oxygen saturation (rScO2), pulse oxymetry (SpO2), mean arterial blood pressure (MABP), and transcutaneous partial pressure of carbon dioxide (TcPCO2) were collected at 9 predefined time points from 1 min before to 60 min after the first drug injection. The two primary outcomes were a decrease in rScO2 value >20% from baseline and a decrease in fractional cerebral tissue oxygen extraction (FTOE) value >10% from baseline, at any time point. Secondary outcomes included physiological parameters changes over time and correlations between mean arterial blood pressure, and FTOE at different time points. Descriptive results were obtained and exploratory statistical analyses were performed for 24 included patients. Results: rScO2 decreased in 5/11 (46%) infants from the Prop group and 10/13 (77%) from the SufTrac group (p = 0.11); FTOE decreased in 10/11 (91%) infants from the Prop group, and 12/13 (92%) from the SufTrac group (p = 0.90). rScO2 values decreased over time in both groups, whereas FTOE's pattern appeared more stable. SpO2 and transcutaneous TcPCO2 seemed more preserved in the Prop group while MABP seemed more preserved in the SufTrac group. No important correlation was observed between MABP and FTOE (r = 0.08 to 0.12 across the time points). Conclusion: Our results suggest a frequent decrease in cerebral oxygenation without obvious impairment in cerebral autoregulation during neonatal intubation with premedication. This study confirms the feasibility and the informative value of cerebral NIRS monitoring in this setting. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02700893.
Collapse
Affiliation(s)
- Meryl Vedrenne-Cloquet
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,Pediatric Intensive Care Unit, Necker University Hospital, Paris, France
| | - Sophie Breinig
- Neonatal and Pediatric Intensive Care Unit, Toulouse University Hospital, Toulouse, France
| | - Agnes Dechartres
- Inserm U1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Département Biostatistique santé publique, information médicale-Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université, Paris, France
| | - Camille Jung
- Clinical Research Center, CHI Créteil, Créteil, France
| | - Sylvain Renolleau
- Pediatric Intensive Care Unit, Necker University Hospital, Paris, France
| | - Laetitia Marchand-Martin
- INSERM, UMR1153, Obstetrical, Perinatal and Paediatric Epidemiology (Epopé) Team, Epidemiology and Biostatistics Sorbonne, Paris Descartes University, Paris, France
| | - Xavier Durrmeyer
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,Faculté de Médecine de Créteil, IMRB, GRC CARMAS, Université Paris Est Créteil, Créteil, France
| |
Collapse
|
27
|
Chollat C, Maroni A, Aubelle MS, Guillier C, Patkai J, Zana-Taïeb E, Keslick A, Torchin H, Jarreau PH. Efficacy and Safety Aspects of Remifentanil Sedation for Intubation in Neonates: A Retrospective Study. Front Pediatr 2019; 7:450. [PMID: 31788457 PMCID: PMC6853995 DOI: 10.3389/fped.2019.00450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/17/2019] [Indexed: 01/05/2023] Open
Abstract
Objective: To evaluate the efficacy and safety of remifentanil as a premedication in neonates undergoing elective intubation. Study Design: This retrospective study focused on neonates admitted to the Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, France, between June 2016 and November 2017, who received remifentanil before an elective intubation. First, atropine (10 μg/kg) was administered intravenously as a bolus, followed by remifentanil, which was administrated continuously. The dose of remifentanil was reduced twice during the study period in order to administer the minimum effective dose and thus reduce possible adverse events. Results: Fifty-four neonates were exposed to remifentanil and atropine. The intubating conditions were excellent or good for 46 procedures (85%) and the median Acute Pain in Newborn Infants score was 2 (IQ 25-75: 0-5) before the sedation, 1 (0-2) during the laryngoscopy, and 0 (0-0) after the intubation. The intubation was successful at the first attempt for 18 patients (33%). Chest wall rigidity occurred in 6 procedures (11%), other respiratory problems in 5 (9%), and laryngospasm in 1 (2%). Some of the procedures were complicated by bradycardia (23%) or desaturation (37%). Conclusions: Remifentanil and atropine prior to intubation provided satisfactory intubating conditions in neonates. Nevertheless, severe adverse effects (such as chest wall rigidity) are a potential risk, possibly related to the total dose received. These data do not support the safety of using remifentanil alone prior to intubation in neonates.
Collapse
Affiliation(s)
- Clément Chollat
- Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, APHP, Paris Descartes University, Paris, France
| | - Arielle Maroni
- Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, APHP, Paris Descartes University, Paris, France
| | - Marie-Stéphanie Aubelle
- Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, APHP, Paris Descartes University, Paris, France
| | - Cyril Guillier
- Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, APHP, Paris Descartes University, Paris, France
| | - Juliana Patkai
- Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, APHP, Paris Descartes University, Paris, France
| | - Elodie Zana-Taïeb
- Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, APHP, Paris Descartes University, Paris, France
| | - Aurélie Keslick
- Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, APHP, Paris Descartes University, Paris, France
| | - Héloïse Torchin
- Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, APHP, Paris Descartes University, Paris, France
| | - Pierre-Henri Jarreau
- Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, APHP, Paris Descartes University, Paris, France
| |
Collapse
|
28
|
Affiliation(s)
- Frank Fideler
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tuebingen, Germany
| | - Christian Grasshoff
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tuebingen, Germany
| |
Collapse
|
29
|
Affiliation(s)
- Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Creteil, France
| | | | - Agnes Dechartres
- Department of Biostatistics, Public Health and Biomedical Information, Pitié Salpetrière-Charlefoix Hospital (AP-HP), Paris, France
| |
Collapse
|