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Walter-Nicolet E, Courtois E, Milesi C, Ancel PY, Beuchée A, Tourneux P, Benhammou V, Carbajal R, Durrmeyer X. Premedication practices for delivery room intubations in premature infants in France: Results from the EPIPAGE 2 cohort study. PLoS One 2019; 14:e0215150. [PMID: 30970001 PMCID: PMC6457540 DOI: 10.1371/journal.pone.0215150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 03/27/2019] [Indexed: 11/19/2022] Open
Abstract
Objectives To assess premedication practices before tracheal intubation of premature newborns in the delivery room (DR). Study design From the national population-based prospective EPIPAGE 2 cohort in 2011, we extracted all live born preterms intubated in the DR in level-3 centers, without subsequent circulatory resuscitation. Studied outcomes included the rate and type of premedication, infants’ and maternities’ characteristics and survival and major neonatal morbidities at discharge from hospital. Univariate and multivariate analysis were performed and a generalized estimating equation was used to identify factors associated with premedication use. Results Out of 1494 included neonates born in 65 maternities, 76 (5.1%) received a premedication. Midazolam was the most used drug accounting for 49% of the nine drugs regimens observed. Premedicated, as compared to non premedicated neonates, had a higher median [IQR] gestational age (30 [28–31] vs 28 [27–30] weeks, p<10−3), median birth weight (1391 [1037–1767] vs 1074 [840–1440] g, p<10−3) and median 1-minute Apgar score (8 [6–9] vs 6 [3–8], p<10−3). Using univariate analyses, premedication was significantly less frequent after maternal general anesthesia and during nighttime and survival without major morbidity was significantly higher among premedicated neonates (56/73 (81.4%) vs 870/1341 (69.3%), p = 0.028). Only 10 centers used premedication at least once and had characteristics comparable to the 55 other centers. In these 10 centers, premedication rates varied from 2% to 75%, and multivariate analysis identified gestational age and 1-minute Apgar score as independent factors associated with premedication use. Conclusion Premedication rate before tracheal intubation was only 5.1% in the DR of level-3 maternities for premature neonates below 34 weeks of gestation in France in 2011 and seemed to be mainly associated with centers’ local policies.
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Affiliation(s)
| | - Emilie Courtois
- Paediatric Emergency Department. Trousseau Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Christophe Milesi
- Paediatric and Neonatal Intensive Care Unit, University Hospital Arnaud de Villeneuve, Montpellier, France
| | - Pierre-Yves Ancel
- INSERM, U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
- Paris Descartes University France, Paris, France
- URC - CIC P1419, Cochin Hotel-Dieu Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Alain Beuchée
- Division of Neonatology and CIC-1414, Department of Pediatrics, University Hospital, Rennes, France
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
| | - Pierre Tourneux
- Neonatal and Paediatric Intensive Care Unit, University hospital, Amiens, France
- PériTox - UMI 01, Medicine University, Picardie Jules Verne University, Amiens, France
| | - Valérie Benhammou
- INSERM, U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
- Paris Descartes University France, Paris, France
| | - Ricardo Carbajal
- Paediatric Emergency Department. Trousseau Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
- INSERM, U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Paris, France
- Paris Descartes University France, Paris, France
- Paediatric and Neonatal Intensive Care Unit, 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
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Prospective follow-up of a cohort of preterm infants<33 WG receiving ketamine for tracheal intubation in the delivery room: Neurological outcome at 1 and 2 years. Arch Pediatr 2018; 25:295-300. [PMID: 29628409 DOI: 10.1016/j.arcped.2018.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Although ketamine analgesia is effective in reducing pain and facilitating the tracheal intubation of newborns in the delivery room, no data on the neurological effects of this treatment are available. This study compared the neurodevelopmental outcomes at 2 years of age in a cohort of preterm newborns having received ketamine prior to tracheal intubation at birth (the ketamine group) and in a control group. METHODS We included newborns delivered at less than 33 weeks gestational age (WGA) having undergone tracheal intubation at birth. The Ages and Stages Questionnaire (ASQ) was completed at 1 and 2 years of age. The development quotient (DQ) was calculated from the revised Brunet-Lezine score assessed at a corrected age of 2 years. RESULTS There were no statistically significant differences between the ketamine group (n=54 at 1 year and n=51 at 2 years) and the control group (n=16 at 1 and 2 years) in terms of the mean±standard deviation DQ at the age of 2 (98±12 vs. 103±9, respectively; P=0.17) and the ASQ score at the age of 2 (221±44 vs. 230±39, respectively; P=0.55). DISCUSSION This prospective cohort of 51 preterm newborns having received ketamine at birth did not reveal any differences in terms of neurological development at the age of 2 (relative to a control group and the literature data). These preliminary results must be confirmed in a randomized trial with longer follow-up.
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[A survey on premedication prior to intubation in very preterm infants (28-32WG) with respiratory distress syndrome in French neonatal intensive care units]. Arch Pediatr 2017; 24:843-849. [PMID: 28734807 DOI: 10.1016/j.arcped.2017.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 03/04/2017] [Accepted: 06/21/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION/OBJECTIVES Tracheal intubation is a painful procedure for which the routine use of analgesia is recommended. However, the use of premedication for intubation is not yet generalized and there is great diversity in the drugs used. The main objective of this study was to describe the frequency of premedication use in preterm neonates aged between 28 and 32weeks of gestation, intubated for respiratory distress syndrome. Secondary objectives were to describe the existence of a written protocol, its influence on the frequency of premedication and the drugs used. MATERIALS AND METHODS Declarative survey on Google.docs forms addressed to physicians and residents working in neonatal intensive care units in France. RESULTS One hundred thirty respondents from 64 units completed this survey between 1 June and 31 July 2014. Fifty-seven percent of respondents declared always using a premedication, and 64 % of participants had a written protocol in their units. Persons working in a unit with a written protocol more frequently reported using premedication (P=0.04). The drugs used were various (mostly a hypnotic/morphine combination) and their dosages scattered. DISCUSSION The results found by this survey confirm data from the literature and the situation seems to have stagnated over the last few years. A written protocol might encourage premedication use. CONCLUSION Improvements in practices and increased knowledge are required to generalize the sedation/analgesia practices for tracheal intubation in neonatal intensive care units in France.
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Hss AS, Linus-Lojikip S, Ismail Z, Ishahar NH, Yusof SS. Neonatal preintubation sedation: a national survey in Malaysia. BMC Res Notes 2015; 8:660. [PMID: 26553069 PMCID: PMC4638092 DOI: 10.1186/s13104-015-1653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/29/2015] [Indexed: 12/02/2022] Open
Abstract
Background There is a shift of practice towards administering sedation in neonates around the world. At the present moment, there is no available data or literature on the practice of sedation before intubation of neonates in Malaysia thus, evaluation of these practice was not possible. This study was conducted to evaluate neonatal preintubation sedation practice and the availability of neonatal preintubation sedation policy in government, university and private Malaysian Neonatal Intensive Care Units (NICUs) in 2007. Methods All 43 NICUs in Malaysia were identified and approached to participate in the study. Phone interviews with doctors’ in-charge of NICUs were conducted in 29 governments, 3 universities and in 7 private NICUs. Results Only 7 NICUs had written policy on neonatal preintubation sedation
use. Seventy-seven percent and 97.4 % of NICUs used sedation during emergency intubation and during planned intubation respectively. Sixty seven percent used either morphine or midazolam with no preference of either drug. Conclusion This study showed a significant proportion of NICUs used sedation during emergency or planned intubation. However, the majority does not write policy on neonatal preintubation sedation use (82.1 %). The types and drug administration methods are not standardized in all of the NICUs. This will require a standard national written policy to be developed.
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Affiliation(s)
- Amar-Singh Hss
- Pediatric Department and Clinical Research Centre Perak, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30990, Ipoh, Perak, Malaysia.
| | - Sharon Linus-Lojikip
- Clinical Research Centre Perak, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30990, Ipoh, Perak, Malaysia.
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[Is it acceptable in 2014 that three-quarters of newborns are intubated without any sedation in the delivery room?]. Arch Pediatr 2014; 21:929-31. [PMID: 25053120 DOI: 10.1016/j.arcped.2014.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 03/31/2014] [Accepted: 06/12/2014] [Indexed: 11/23/2022]
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Walter-Nicolet E, Zanichelli C, Coquery S, Cimerman P. [Implementation of a specific premedication protocol for tracheal intubation in the delivery room. Practice in two level-III hospitals]. Arch Pediatr 2014; 21:961-7. [PMID: 24726672 DOI: 10.1016/j.arcped.2014.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 11/18/2013] [Accepted: 02/15/2014] [Indexed: 11/19/2022]
Abstract
UNLABELLED Tracheal intubation in neonates is a painful procedure performed daily in the delivery room despite the widespread development of noninvasive ventilation. Specific analgesia is not commonly performed. The objective of this observational study was to compare practices between two level-III centers: one with a specific protocol for premedication before tracheal intubation of newborns in the delivery room, the other without. RESULTS One hundred and fifteen neonates were intubated in the delivery room and included over a 4-month period: 25% of them received specific premedication before intubation, exclusively in the center with the protocol. None of the extreme premature neonates (age≤28 gestational weeks) received analgosedation before the procedure. Nalbuphine, midazolam, and sufentanil were mainly used, via the intravenous or intrarectal route. Infants receiving a premedication were significantly heavier and had a greater gestational age than the others (1500 g [range, 1180-2260 g] vs. 1170 [range, 860-1680 g] P=0.003, and 31 GW [range, 29-34 GW] vs. 29 [range, 27-32 GW] P=0.014, respectively). Most pediatricians (85-100%) favored a specific protocol for sedation before tracheal intubation. Implementation of a specific protocol allows specific analgesia to be implemented for newborns undergoing tracheal intubation. Further studies should be conducted to determine the best strategies for pain management during tracheal intubation of neonates, especially in the delivery room.
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Affiliation(s)
- E Walter-Nicolet
- Service de néonatologie, hôpital Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France; Service de néonatologie, hôpital Trousseau, AP-HP, 26, avenue Arnold-Netter, 75012 Paris, France.
| | - C Zanichelli
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - S Coquery
- Service de néonatologie, hôpital Antoine-Béclère, AP-HP, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France
| | - P Cimerman
- Centre national de ressources contre la douleur, hôpital Trousseau, AP-HP, 26, avenue Arnold-Netter, 75012 Paris, France
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Intubation in the delivery room: experience with nasal midazolam. Early Hum Dev 2014; 90:39-43. [PMID: 24331827 DOI: 10.1016/j.earlhumdev.2013.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 10/22/2013] [Accepted: 10/29/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Neonates are often intubated in the delivery room (DR) without anesthesia because vascular access is impossible. AIMS To assess neonatal comfort and adverse events after use of nasal midazolam (nMDZ) for intubation in the DR. STUDY DESIGN Prospective data collection over 6months on the intubation of neonates with respiratory distress requiring tracheal instillation of surfactant. SUBJECTS Twenty-seven neonates with median (Q25-75) gestational age and birthweight of, respectively, 29 (27-33)weeks and 1270 (817-1942)g received a 0.1mg/kg dose of nMDZ, and intubation was performed at the onset of tonus resolution or apnea. OUTCOME MEASURES Comfort was assessed with a scale of hetero-pain assessment and electrical skin conductance monitoring. Continuous pulse oximetry was recorded in the first postnatal hour, with oscillometric blood pressure measurement every 10min. RESULTS Seventy percent of the patients required a single dose, with intubation performed 4.8 (3-9)min after administration. Combined electro-clinical assessment found adequate comfort during the procedure in 68% of neonates. Mean blood pressure decreased from 39 (34-44)mmHg before to 31 (25-33)mmHg 1h following nMDZ (p=0.011). CONCLUSION nMDZ provided rapid and effective sedation to intubate neonates in the DR but potentially exposed them to hypotension, thus requiring close hemodynamic monitoring.
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Barois J, Tourneux P. Ketamine and atropine decrease pain for preterm newborn tracheal intubation in the delivery room: an observational pilot study. Acta Paediatr 2013; 102:e534-8. [PMID: 24015945 DOI: 10.1111/apa.12413] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 08/08/2013] [Accepted: 09/03/2013] [Indexed: 11/29/2022]
Abstract
AIM Various analgesic strategies are used before tracheal intubation of preterm newborns in the delivery room, due to the lack of a standard protocol and difficult venous access. This study evaluated the feasibility and efficacy of short venous catheter insertion and immediate ketamine analgesia for tracheal intubation of preterm newborns at birth in the delivery room. METHODS Prospective observational pilot study, with ketamine and atropine used at the paediatrician's discretion. Pain score, heart rate, SpO2 nadirs, procedure duration and neonatal intensive care unit morbidity were recorded. RESULTS Fifty-seven consecutive preterm newborns were included between January I and June 30, 2012: 15 in the no analgesia group and 39 in the intravenous ketamine group. Short catheter insertion failed in three newborns. The pain score was lower during laryngoscopy in the ketamine group (4 ± 0.7 vs. 2.9 ± 3.2 in the no analgesia group, p < 0.001). The heart rate nadir during tracheal intubation was 150.7 ± 29.6 bpm (vs. 112.6 ± 35.5 bpm in the no analgesia group, p < 0.01). Surfactant therapy was administered to 79.5% of newborns in the ketamine group (vs. 92.3%, p = 0.29) in the first 30 min of life. CONCLUSION Short venous catheter insertion with immediate ketamine analgesia plus atropine for tracheal intubation of preterm newborns in the delivery room was effective in decreasing pain and preventing vagal bradycardia.
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Affiliation(s)
- J Barois
- Médecine et Réanimation Néonatale; CH Valenciennes; Valenciennes France
| | - P Tourneux
- Médecine néonatale et Réanimation pédiatrique; CHU Amiens; Amiens France
- PériTox (EA 4285 - UMI 01 INERIS); UFR de Médecine; Université de Picardie Jules Verne; Amiens France
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Biban P, Gaffuri M. Premedication for tracheal intubation: any good reason for treating newborn infants differently? Pediatr Crit Care Med 2013; 14:441-2. [PMID: 23648878 DOI: 10.1097/pcc.0b013e31827d1637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Premedication for neonatal endotracheal intubation: results from the epidemiology of procedural pain in neonates study. Pediatr Crit Care Med 2013; 14:e169-75. [PMID: 23439457 DOI: 10.1097/pcc.0b013e3182720616] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe the frequency and nature of premedications used prior to neonatal endotracheal intubation; to confront observed practice with current recommendations; and to identify risk factors for the absence of premedication. DESIGN, SETTING, AND PATIENTS Data concerning intubations were collected prospectively at the bedside as part of an observational study collecting around-the-clock data on all painful or stressful procedures performed in neonates during the first 14 days of their admission to 13 tertiary care units in the region of Paris, France, between 2005 and 2006. INTERVENTION Observational study. MEASUREMENTS AND MAIN RESULTS Specific premedication prior to endotracheal intubation was assessed. Ninety one intubations carried out on the same number of patients were analyzed. The specific premedication rate was 56% and included mostly opioids (67%) and midazolam (53%). Compared with recent guidance from the American Academy of Pediatrics, used premedications could be classified as "preferred" (12%), "acceptable" (18%), "not recommended" (27%), and "not described" (43%). In univariate analysis, infants without a specific premedication compared with others were younger at the time of intubation (median age: 0.7 vs. 2.0 days), displayed significantly more frequent spontaneous breathing at the time of intubation (31% vs. 12%) and a higher percentage of analgesia for all other painful procedures (median values: 16% vs. 6%). In multivariate analysis, no factor remained statistically significant. CONCLUSIONS Premedication use prior to neonatal intubation was not systematically used and when used it was most frequently inconsistent with recent recommendations. No patient- or center-related independent risk factor for the absence of premedication was identified in this study.
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Enquête nationale sur la prise en charge de la douleur liée à l’intubation trachéale du nouveau-né dans les maternités de niveau III. Arch Pediatr 2013; 20:123-9. [DOI: 10.1016/j.arcped.2012.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Revised: 05/15/2012] [Accepted: 11/05/2012] [Indexed: 11/18/2022]
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Wheeler B, Broadbent R, Reith D. Premedication for neonatal intubation in Australia and New Zealand: a survey of current practice. J Paediatr Child Health 2012; 48:997-1000. [PMID: 23039075 DOI: 10.1111/j.1440-1754.2012.02589.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM This study aims to describe the current approach to intubation premedication in neonatal intensive care units (NICUs) in Australia and New Zealand. METHODS A literature review regarding intubation premedication in the newborn was carried out to inform questionnaire design. A web-based survey of 28 NICUs and two neonatal emergency transport services was conducted and supplemented by telephone contact to ensure completion. RESULTS All the tertiary NICUs and neonatal emergency transport services in Australia and New Zealand use premedication for elective intubation of neonates. Eighty per cent of units have a written policy. There were 28 of 30 units (93%) that use muscle relaxants, mostly suxamethonium. The choice of sedative medication is varied. CONCLUSIONS Australian and New Zealand neonatal units have a high use of intubation premedication including muscle relaxants, but vary considerably in their choice of sedative medication.
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Affiliation(s)
- Ben Wheeler
- Department of Women's and Child Health, University of Otago, Dunedin, New Zealand.
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Durrmeyer X, Vutskits L, Anand KJS, Rimensberger PC. Use of analgesic and sedative drugs in the NICU: integrating clinical trials and laboratory data. Pediatr Res 2010; 67:117-27. [PMID: 20091937 DOI: 10.1203/pdr.0b013e3181c8eef3] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Recent advances in neonatal intensive care include and are partly attributable to growing attention for comfort and pain control in the term and preterm infant requiring intensive care.Limitation of painful procedures is certainly possible, but most critically ill infants require unavoidable painful or stressful procedures such as intubation, mechanical ventilation, or catheterization.Many analgesics (opioids and nonsteroidal anti-inflammatory drugs)and sedatives (benzodiazepines and other anesthetic agents) are available but their use varies considerably among units. This review summarizes current experimental knowledge on the effects of sedative and analgesic drugs on brain development and reviews clinical evidence that speaks for or against the use of common analgesic and sedative drugs in the NICU but avoids any discussion of anesthesia during surgery. Risk/benefit ratios of intermittent boluses or continuous infusions for the commonly used sedative and analgesic agents are discussed in the light of clinical and experimental studies. The limitations of extrapolating experimental results from animals to humans must be considered while making practical recommendations based on the currently available evidence.
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Affiliation(s)
- Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil 94000, France
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Abstract
Tracheal intubation is performed frequently in the NICU and delivery room. This procedure is extremely distressing, painful, and has the potential for airway injury. Premedication with sedatives, analgesics, and muscle relaxants is standard practice for pediatric and adult intubation, yet the use of these drugs is not common for intubation in neonates. The risks and benefits of using premedications for intubating unstable newborns are hotly debated, although recent evidence shows that premedication for non-urgent or semi-urgent intubations is safer and more effective than awake intubations. This article reviews clinical practices reported in surveys on premedication for neonatal intubation, the physiological effects of laryngoscopy and intubation on awake neonates, as well as the clinical and physiological effects of different drug combinations used for intubation. A wide variety of drugs, either alone or in combination, have been used as premedication for elective intubation in neonates. Schematically, these studies have been of three main types: (a) studies comparing awake intubation versus those with sedation or analgesia, (b) studies comparing different premedication regimens comprising sedatives, analgesics, and anesthetics, and (c) case series of neonates in which some authors have reported their experience with a specific premedication regimen. The clinical benefits described in these studies and the need for pain control in neonates make the case for using appropriate premedication routinely for elective or semi-urgent intubations. Tracheal intubation without the use of analgesia or sedation should be performed only for urgent resuscitations in the delivery room or other life-threatening situations when intravenous access is unavailable.
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Affiliation(s)
- Ricardo Carbajal
- Centre National de Ressources de lutte contre la Douleur, Hôpital d'Enfants Armand Trousseau, Paris, France.
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