Should we reconsider awake neonatal intubation? A review of the evidence and treatment strategies

Analgosedation before Less-Invasive Surfactant Administration: A Systematic Review

BACKGROUND

Surfactant therapy is the cornerstone of respiratory distress syndrome management. "Less-invasive surfactant administration (LISA)" is now recommended for spontaneously breathing preterm infants. Analgosedation remains controversial as 52% of European neonatologists do not use any. This systematic review aims to describe the efficacy and safety of different drugs for analgosedation during LISA.

METHODS

MEDLINE via Ovid, Embase, Scopus, and Cochrane Library of Trials were searched independently by 2 reviewers for studies on sedation or analgesia for LISA, without filters or limits.

RESULTS

Eight studies (1 randomized controlled trial) recruiting 945 infants were included. Infant pain was significantly reduced, with more infants evaluated as comfortable. Failure, defined as need for intubation or for a second dose of surfactant, was not different between sedated and unsedated groups. Analgosedation was associated with a higher occurrence of desaturation and need for positive pressure ventilation during procedure, but the need for mechanical ventilation within 24 or 72 h of life was not significantly different. There does not seem to be any difference in clinical tolerance and complications (e.g., hypotension, mortality, air leaks, etc.). Procedural conditions were evaluated as good or excellent in 83% after sedation.

DISCUSSION AND CONCLUSION

Analgesia or sedative drugs increase infant comfort and allow good procedural conditions, with a limited impact on the clinical evolution. Questions remain about the best choice of drugs and dosages, with the constraint to maintain spontaneous breathing and have a rapid offset. Further good quality studies are needed to provide additional evidence to supplement those limited existing data.

Premedication with paralysis improves intubation success and decreases adverse events in very low birth weight infants: a prospective cohort study

OBJECTIVE

To characterize the impact of premedication with and without a paralytic agent on the safety of tracheal intubation (TI) in infants ≤1500 g.

STUDY DESIGN

A prospective observational cohort study between February 2015 and June 2017. The primary outcomes were associations between the use of different premedication regimens with number of TI attempts, TI adverse events (TIAEs), and changes in heart rate.

RESULTS

Data were collected on 237 TIs. Median postmenstrual age at intubation was 28 completed weeks and weight was 953 g. Premedication with a paralytic was associated with fewer intubation attempts compared to premedication without a paralytic (p = 0.037). Premedication with a paralytic was associated with fewer TIAEs (p < 0.001) and less bradycardia compared to the other two regimens (p = 0.003) compared to premedication without a paralytic.

CONCLUSIONS

Premedication with a paralytic was associated with fewer intubation attempts, fewer TIAEs, and less bradycardia. Premedication with a paralytic may improve intubation safety in VLBWs.

Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial

OBJECTIVE

To compare the effectiveness of sedation by intranasal administration of midazolam (nMDZ) or ketamine (nKTM) for neonatal intubation.

DESIGN

A multicentre, prospective, randomised, double-blind study.

SETTING

Delivery rooms at four tertiary perinatal centres in France.

PATIENTS

Preterm neonates with respiratory distress requiring non-emergent endotracheal intubation for surfactant instillation.

INTERVENTIONS

Treatment was randomly allocated, with each neonate receiving a bolus of 0.1 mL/kg in each nostril, corresponding to 0.2 mg/kg for nMDZ and 2 mg/kg for nKTM. The drug was repeated once 7 min later at the same dose if adequate sedation was not obtained.

MAIN OUTCOME MEASURES

Success was defined by adequate sedation before intubation and adequate comfort during the procedure. Intubation features, respiratory and cardiovascular events were recorded.

RESULTS

Sixty newborns, with mean (SD) gestational age and birth weight of 28 (3) weeks and 1100 (350) g, were included within the first 20 min of life. nMDZ was associated with a higher success rate (89% vs 58%; RR: 1.54, 95% CI 1.12 to 2.12, p<0.01) and shorter delays between the first dose and intubation (10 (6) vs 16 (8) min, p<0.01).Number of attempts, time to intubation, mean arterial blood pressure measures over the first 12 hours after birth and length of invasive ventilation were not different.

CONCLUSIONS

nMDZ was more efficient than nKTM to adequately sedate neonates requiring intubation in the delivery room. The haemodynamic and respiratory effects of both drugs were comparable.

CLINICAL TRIAL

This clinical trial was recorded on the National Library of Medicine registry (NCT01517828).

Infection Risk Reduction in the Intensive Care Nursery: A Review of Patient Care Practices That Impact the Infection Risk in Global Care of the Hospitalized Neonates

Neonates are at high risk for developing an infection during their hospital stay in the neonatal intensive care unit. Increased risk occurs because of immaturity of the neonate's immune system, lower gestational age, severity of illness, surgical procedures, and instrumentation with life support devices such as vascular catheters. Neonates become colonized with bacteria prior to or at delivery and also during their hospital stay. They can then become infected with those bacteria if there is a breakdown in the primary defenses such as tissue injury due to skin breakdown, nasal erosion, or trauma to the respiratory tract. Neonates are also at high risk for bacterial translocation due to the altered permeability of the intestinal mucosa, loss of commensal flora, and bacterial overgrowth. The unit-based neonatal care team must implement global care delivery and safety practices, utilize published care guidelines, know and apply evidence-based practices from collaborative quality improvement efforts and other sources, and use auditing and monitoring practices that can identify risks and lead to better practice options to prevent infections. This article presents several aspects of global neonatal care delivery, including vascular access, which may reduce the risk of systemic infection during the hospitalization.

The management of difficult intubation in infants: a retrospective review of anesthesia record database

We retrospectively reviewed the anesthesia records of infants < 1 year of age for elucidating the incidence of difficult intubation and airway management in a single general hospital. The electronic data records from a total of 753 consecutive anesthesiological procedures in 513 different infants were analyzed. After excluding data with a lack of records of laryngoscopic findings, a total of 497 procedures (389 different infants) with either remarks of difficult intubation (requiring > 10 min for tracheal intubation) or records of Cormack-Lehane grade were included. Demographic data are median age 5 (range, 0–11) months, height 61 (33–84) cm, body weight 6.0 (1.1 − 11.8) kg. The number of cases with ASA physical status I, II, III and IV was 182 (36.6 %), 135 (27.3 %), 177 (35.5 %) and 3 (0.6 %), respectively. Cormack-Lehane grade 1, 2, 3 and 4 was seen in 450 (90.5 %), 32 (6.4 %), 6 (1.2 %) and 6 (1.2 %) cases, respectively.

Document of difficult intubation was found in 12 cases (2.4 %, 10 different infants) with a lack of record of Cormack-Lehane grade in 3 cases. Of these 10 infants, nine had multiple congenital anomalies including heart diseases and cleft palate. Without premedication, general anesthesia was induced with intravenous midazolam or sevoflurane in the 12 cases. Tracheal intubation was performed after disappearance of spontaneous respiration except three cases who were intubated in the awake state or under sedation. Elapsed time from induction of anesthesia to intubation was 17 (14–29) min. Although mask ventilation was adequate in all cases, two cases (one infant) developed hypoxia and bradycardia during tracheal intubation. No remarkable decrease of SpO₂ or bradycardia less than 100 bpm was detected in other cases. In conclusion, we found difficult intubation in 2.4 % of infants undergoing general anesthesia. Although muscle relaxants are useful for facilitating tracheal intubation, it should be carefully used with the preparation of other airway devices in infants with predicted difficult intubation.

Gas induction for pyloromyotomy

BACKGROUND

Infants with pyloric stenosis are considered to be at high risk of aspiration on induction of anesthesia. Traditionally, texts have recommended classic rapid sequence induction (RSI) or awake intubation (AI). AI has generally fallen out of favor, while the components of RSI have become increasingly controversial. Infants are at high risk of hypoxemia if ventilation is not maintained while waiting for neuromuscular blockade to establish. The efficacy of cricoid pressure (CP) to prevent aspiration has not been proven. It can impair visualization of the glottis and make intubation difficult. It is debatable whether any RSI technique is needed for pyloromyotomy. A recent review of 235 infants reported no aspiration events. These children were anesthetized with a variety of techniques, including RSI, gas induction, and AI. In our institution, we teach a gaseous induction. The nasogastric tube is used to empty the stomach and anesthesia is induced with sevoflurane. A nondepolarizing muscle relaxant is administered and ventilation maintained until neuromuscular blockade is established and intubating conditions are optimal. We report our experience of this technique.

METHOD

A retrospective medical notes review of all patients undergoing pyloromyotomy between 2005 and 2012.

RESULTS

There were 269 patients (84.4% male, mean weight 3.74 kg ± 0.74). Two hundred and fifty-two (93.7%) received gas inductions and 17 (6.3%) intravenous (IV) inductions. Two children received an RSI. No patient-specific factors were identified to explain operator choice in those receiving IV inductions. There were no recorded aspiration events.

CONCLUSION

Gas induction can be considered for children undergoing pyloromyotomy.

Nebulisation Versus Spray-as-You-Go Airway Topical Anaesthesia in Patients with Temporomandibular Joint Ankylosis using 2 % Lignocaine

STUDY DESIGN

This randomized, comparative clinical study was designed to compare 2 % lignocaine nebulization and 2 % lignocaine via spray-as-you-go technique for topical airway anaesthesia during or awake flexible fiberoptic intubation (AFOI) in temporomandibular joint (TMJ) ankylosis patients.

METHODS

Sixty adult patients with TMJ ankylosis were randomly assigned to the following study groups using a computer generated random number table 2 % lignocaine nebulised (group A) and 2 % lignocaine via spray-as-you-go technique (group B). After airway anaesthesia, awake flexible fiberoptic nasotracheal intubation was performed. An independent investigator who did not participate in the study scored patients' comfort during airway topical anaesthesia and patients' reaction during awake FOI. Changes in haemodynamics during the airway manipulation were also observed.

RESULTS

There were no statistically significant differences in the observed variables between the two groups.

CONCLUSIONS

Both 2 % lignocaine nebulization and 2 % lignocaine spray-as-you-go technique provided acceptable conditions for AFOI in TMJ patients.

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

Objective:

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

Methods:

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

Findings:

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

Conclusion:

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Pain management in neonates

Multiple lines of evidence suggest an increased sensitivity to pain in neonates. Repeated and prolonged pain exposure may affect the subsequent development of pain systems, as well as potentially contribute to alterations in long-term development and behavior. Despite impressive gains in the knowledge of neonatal pain mechanisms and strategies to treat neonatal pain acquired during the last 15 years, a large gap still exists between routine clinical practice and research results. Accurate assessment of pain is crucial for effective pain management in neonates. Neonatal pain management should rely on current scientific evidence more than the attitudes and beliefs of care-givers. Parents should be informed of pain relief strategies and their participation in the health care plan to alleviate pain should be encouraged. The need for systemic analgesia for both moderate and severe pain, in conjunction with behavioral/environmental approaches to pain management, is emphasized. A main sources of pain in the neonate is procedural pain which should always be prevented and treated. Nonpharmacological approaches constitute important treatment options for managing procedural pain. Nonpharmacological interventions (environmental and preventive measures, non-nutritive sucking, sweet solutions, skin-skin contact, and breastfeeding analgesia) can reduce neonatal pain indirectly by reducing the total amount of noxious stimuli to which infants are exposed, and directly, by blocking nociceptive transduction or transmission or by activation of descending inhibitory pathways or by activating attention and arousal systems that modulate pain. Opioids are the mainstay of pharmacological pain treatment but there are other useful medications and techniques that may be used for pain relief. National guidelines are necessary to improve neonatal pain management at the institutional level, individual neonatal intensive care units need to develop specific practice guidelines regarding pain treatment to ensure that all staff are familiar with the effects of the drugs being used and to guarantee access and safe administration of pain treatment to all neonates.

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

OBJECTIVES

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

DESIGN, SETTING, AND PATIENTS

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

INTERVENTION

Observational study.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Premedication for neonatal intubation: Current practice in Saudi Arabia

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULT

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

CONCLUSION

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

Rocuronium for nonemergent intubation of term and preterm infants

OBJECTIVE

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

STUDY DESIGN

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

RESULT

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

CONCLUSION

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

Awake Blind Nasotracheal Intubation in Temporomandibular Joint Ankylosis Patients under Conscious Sedation Using Fentanyl and Midazolam

BACKGROUND AND OBJECTIVES

Intubating a patient with temporomandibular joint ankylosis is always a challenge particularly when fibreoptic laryngoscope is not available. Awake blind nasotracheal intubation requires sufficient patient co operation and comfort. Presently available short-acting analgesics and amnesics are excellent choices for this exercise.

STUDY DESIGN

This prospective randomized double blind study was designed to determine an appropriate dosage of fentanyl for awake blind nasotracheal intubation. We compared two different dosage of fentanyl. Eighty patients were randomly assigned to receive midazolam 0.05 mg/kg and fentanyl 2μg/kg in bolus (group I), or midazolam 0.05 mg/kg, fentanyl 3μg/kg in bolus (group II).

RESULTS

Both dosage regimen ensured patient comfort and sedation. Patients in group II were more calm and sedated as compared to group I. Hemodynamics was also more stable in group II.

CONCLUSION

For awake blind nasotracheal intubation, we therefore recommend midazolam 0.05mg/kg plus fentanyl 3μg/kg in bolus.

Intratracheal catheter suction removes the same volume of meconium with less impact on desaturation compared with meconium aspirator in meconium aspiration syndrome

OBJECTIVE

To evaluate the impact of suction technique on the rate of meconium removal, oxygenation, and hemodynamics in an animal experimental model of meconium aspiration syndrome (MAS).

METHODS

MAS was induced in ventilated rabbits using 3.5 ml/kg of 20% human meconium. Tracheal suction with either catheter suction (CS) or meconium aspirator (MA) was performed after meconium instillation. Percentage of meconium collection rate, PaO(2) trends for 2h after tracheal suction, and acute-phase SpO(2) trends were compared between CS and the other three groups, the tube was withdrawn while meconium was aspirated with an MA, then the trachea was reintubated 5, 10 or 15s after suctioning of meconium.

RESULTS

Percentage of meconium collection rate and PaO(2) showed no significant differences between groups. The MA group taking 15s for reintubation after meconium suctioning, showed a significantly lower acute-phase SpO(2) than the CS group (P<0.05). The time for SpO(2) to return to >or=90% was also longer in the MA group taking 15s for reintubation than in the CS group (P<0.05).

CONCLUSION

Intratracheal CS removed the same volume of meconium with less impact on desaturation compared with meconium aspiration in an animal model of MAS. Intratracheal CS may be benefit to remove meconium in non-vigorous infants with meconium-stained amniotic fluid at birth.

Propofol as an induction agent for endotracheal intubation can cause significant arterial hypotension in preterm neonates

BACKGROUND

Propofol is gaining increasing popularity as induction agent for pediatric endotracheal intubation. Recently, propofol has been described for the first time as induction agent for endotracheal intubation in preterm neonates. Propofol seemed to be efficient, safe and ideally suited for the INSURE (Intubation SURfactant Extubation) procedure in preterm neonates. The purpose of this study was to document intubating conditions, vital signs, extubation times and outcome in preterm neonates receiving propofol as induction agent for the INSURE procedure.

PATIENTS AND METHODS

Preterm neonates with a gestational age of 29-32 weeks and respiratory distress were eligible for INSURE with propofol if their postnatal age was <8 h. Exclusion criteria were any kind of disease not allowing early extubation.

RESULTS

There were 13 inborn neonates enrolled for INSURE, mean gestational age was 30 weeks + 3 days, and mean birth weight was 1428 g (range 1170-1780 g). We stopped our observational study ahead of time as a result of significant cardiovascular side effects. Propofol generally offered good intubating conditions, but we encountered severe problems with arterial hypotension. A low propofol bolus of 1 mg kg(-1) caused a distinctive decline in mean arterial blood pressure from 38 mmHg (range 29-42 mmHg) prior premedication to 24 mmHg (22-40 mmHg) 10 min after propofol application.

CONCLUSIONS

Our experience with propofol as induction agent for endotracheal intubation in preterm neonates reveals distinctive cardiovascular effects, which represent an important risk factor for serious complications of prematurity like intraventricular hemorrhage or periventricular leucomalacia. Propofol should be used with caution in very preterm neonates with respiratory distress during the first hours of life.

Thiopental pharmacokinetics in newborn infants: a case report of overdose

Thiopental may be used for sedation before intubation in newborn infants. A boy, born at 33 weeks of gestation (gw); birth weight 2435 g, was prescribed thiopental 3 mg/kg before intubation. He developed temporary hypotension and oxygen desaturation, and remained unconscious for longer than expected with a suppressed electroencephalography for 48 h. Serum thiopental concentration was 82, 59, 42 and 32 micromol/L after 20 min and 6, 24 and 68 h respectively. Serum concentrations from five newborn infants at the same time points after intubation with the same thiopental dose were used as reference values, and indicated a 10-fold overdose in the index case. The cause of the overdose could not be identified. The infant recovered; cerebral magnetic resonance imaging at the age of 42 gw and psychomotor development at 2 years were normal. These results show that thiopental concentrations are variable in neonates and there is a high risk of dosage error as no specific paediatric formulation is available.

CONCLUSION

Well-designed procedures and continuous education are required to prevent errors and adverse events during drug delivery to newborn infants. To develop a safe method of administration for thiopental, an extended pharmacokinetic and pharmacodynamic study in neonates is warranted.

Use of premedication for intubation in tertiary neonatal units in the United Kingdom

BACKGROUND

Endotracheal intubation and laryngoscopy are frequently performed procedures in neonatal intensive care. These procedures represent profoundly painful stimuli and have been associated with laryngospasm, bronchospasm, hemodynamic changes, raised intracranial pressure and an increased risk of intracranial hemorrhage. These adverse changes can cause significant neonatal morbidity but may be attenuated by the use of suitable premedication.

AIMS

To evaluate current practices for premedication use prior to elective intubation in UK tertiary neonatal units.

METHODS

Telephone questionnaire survey of all 50 tertiary neonatal units in the UK.

RESULTS

Ninety percent of units report the routine use of sedation prior to intubation and 82% of units routinely use a muscle relaxant. Morphine was the most commonly used sedative and suxamethonium was the most commonly used muscle relaxant. Approximately half of the units also used atropine during intubation. Seventy seven percent of units had a written policy for premedication. Ten percent of the units did not routinely use any sedatives or muscle relaxants for elective intubation.

CONCLUSIONS

In comparison with data from a 1998 survey, our study demonstrated an increase in the number of units that have adopted a written policy for premedication use, and in the number routinely using premedication drugs for elective intubation. There remains little consensus as to which drugs should be used and in what dose.

Randomized controlled trial of sevoflurane for intubation in neonates

BACKGROUND

Our aim was to determine whether sevoflurane can be used with safety and efficacy for anesthesia during intubation in term and preterm neonates in a prospective randomized-controlled nonblinded study in a tertiary neonatal intensive care unit.

METHODS

Thirty-three neonates were randomly allocated to receive sevoflurane (inspired concentrations varying from 2% to 5%) or no medication (preoxygenation with 100% oxygen alone) before intubation. Minute by minute heart rate (HR), mean arterial blood pressure, SpO(2) and number of episodes of bradycardia (HR < 100 b.min(-1)) and desaturation (SpO(2) < 85% for >30 s) were noted from 5 min before to 10 min after intubation. Operator experience, ease and number of attempts were noted.

RESULTS

No major adverse events were noted in the study group compared with the control group [hypotension (37.5% vs 37.5%, NS), number of desaturations [37.5% vs 44.5%, NS)]. Hypertension (25%, vs 56.3%P = 0.04) and incidence of bradycardias (8.3% vs 44.4%, P < 0.01) were greater in the control group. Intubation was easier in the study group: no movements: 95.5% vs 28% (P < 0.005); good glottis visualization: 73% vs 33% (P = 0.013). The failure rate was lower in the study group (25% vs 39%), but this difference was not statistically significant.

CONCLUSION

Anesthesia for intubation with sevoflurane in neonates is well tolerated, even in the less mature. It facilitates the conditions for intubation and leads to fewer adverse events. Other studies are necessary to confirm these preliminary results.

Premedication for tracheal intubation in neonates: confusion or controversy?

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.

Sédation–analgésie avant intubation trachéale en réanimation néonatale et en salle de naissance: pratiques en France métropolitaine

Tracheal intubation is a painful procedure commonly used in the neonatal intensive care units and in the delivery rooms. It can be complicated by changes in vital signs.

OBJECTIVE

To ascertain the use of sedatives and/or analgesics before tracheal intubation in French neonatal intensive care units and delivery rooms.

METHODS

A survey by questionnaire sent to 58 neonatal intensive care units and 58 maternities.

RESULTS

We obtained 46 responses (79,3%) from the neonatal intensive care units and 38 (65,5%) from the delivery rooms. In neonatal intensive care units, 74% of the newborns received a sedative and/or an analgesic before being intubated, and 60% of the units had specific written guidelines. Opioïds and benzodiazepines were the main drugs used. In the delivery rooms, sedatives or analgesics were only used in 21% of the centres.

CONCLUSION

The use of sedation-analgesia seems to improve in neonatology but is still insufficient in the delivery rooms. The development of specific guidelines and a best learning about the different drugs are necessary.

Facilitation of neonatal endotracheal intubation with mivacurium and fentanyl in the neonatal intensive care unit

BACKGROUND

Endotracheal intubation in the neonate is painful and is associated with adverse physiological effects. Some premedication regimens have been shown to reduce these effects, but the optimal regimen is not yet determined.

METHOD

Data on semi-elective intubations were prospectively collected in the neonatal intensive care unit over a six month period. Patients received 20 microg/kg atropine, 200 microg/kg mivacurium (a non-depolarising muscle relaxant) followed by 5 microg/kg fentanyl.

RESULTS

Thirty three patients were electively intubated during this time period. The primary reason for intubation was surfactant administration (53%). Median (range) birth weight, gestational age, and age at intubation were 1360 g (675-4200), 29 weeks (25-38), and 33 hours (1-624) respectively. Twenty two of the infants were intubated on the first attempt. Median duration from initial insertion of the laryngoscope to successful intubation was 60 seconds (15 seconds to 20 minutes). In 18 cases, the first attempt was by a trainee with no previous successful intubation experience, 10 of whom intubated within two attempts. Muscle relaxation occurred at a mean (SD) of 94 (51) seconds, and mean (range) time to return of spontaneous movements was 937 seconds (480-1800). Intubation conditions were scored as excellent using a validated intubation scale.

CONCLUSION

Effective analgesia can be administered and intubation performed with some brief desaturations, even when junior personnel are being taught their first intubation. In this first report of mivacurium for intubation in the newborn, effective bag and mask ventilation was easily achieved during muscle relaxation and was associated with excellent intubation conditions, permitting a high success rate for inexperienced personnel.

Analgesia and local anesthesia during invasive procedures in the neonate

BACKGROUND

Preterm and full-term neonates admitted to the neonatal intensive care unit or elsewhere in the hospital are routinely subjected to invasive procedures that can cause acute pain. Despite published data on the complex behavioral, physiologic, and biochemical responses of these neonates and the detrimental short- and long-term clinical outcomes of exposure to repetitive pain, clinical use of pain-control measures in neonates undergoing invasive procedures remains sporadic and suboptimal. As part of the Newborn Drug Development Initiative, the US Food and Drug Administration and the National Institute of Child Health and Human Development invited a group of international experts to form the Neonatal Pain Control Group to review the therapeutic options for pain management associated with the most commonly performed invasive procedures in neonates and to identify research priorities in this area.

OBJECTIVE

The goal of this article was to review and synthesize the published clinical evidence for the management of pain caused by invasive procedures in preterm and full-term neonates.

METHODS

Clinical studies examining various therapies for procedural pain in neonates were identified by searches of MEDLINE (1980-2004), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2004), the reference lists of review articles, and personal files. The search terms included specific drug names, infant-newborn, infant-preterm, and pain, using the explode function for each key word. The English-language literature was reviewed, and case reports and small case series were discarded.

RESULTS

The most commonly performed invasive procedures in neonates included heel lancing, venipuncture, IV or arterial cannulation, chest tube placement, tracheal intubation or suctioning, lumbar puncture, circumcision, and SC or IM injection. Various drug classes were examined critically, including opioid analgesics, sedative/hypnotic drugs, nonsteroidal anti-inflammatory drugs and acetaminophen, injectable and topical local anesthetics, and sucrose. Research considerations related to each drug category were identified, potential obstacles to the systematic study of these drugs were discussed, and current gaps in knowledge were enumerated to define future research needs. Discussions relating to the optimal design for and ethical constraints on the study of neonatal pain will be published separately. Well-designed clinical trials investigating currently available and new therapies for acute pain in neonates will provide the scientific framework for effective pain management in neonates undergoing invasive procedures.

Douleur du nouveau-né : traitement pharmacologique

Pain causes numerous physiological changes in neonates. All invasive procedures induce undesirable stress responses; theses responses can, however, be eliminated or reduced by a judicious use of analgesia. Even though a large number of analgesics and sedatives are currently available, most of them have not been studied in the neonate. At present, a precise understanding of the pharmacological mechanisms of analgesics is difficult because many interactions still remain unknown in the term and premature neonate. This article describes the main analgesics and sedative agents used in the neonate: morphine, fentanyl, sufentanil, alfentanil, nalbuphine, ketamine, midazolam, propofol, acetaminophen, and Emla cream. After a review of the literature regarding these drugs, some practical advices and suggestions for the treatment of procedure-induced pain, and background sedation/analgesia for ventilated neonates are given. It is also stated in this article that the best way to soothe pain in neonates is to combine non pharmacological and pharmacological strategies. At the national level, written guidelines should be prepared in order to improve pain management in the neonate.

Premedication for tracheal intubation: A prospective survey in 75 neonatal and pediatric intensive care units*

OBJECTIVE

In children, like in adults, tracheal intubation is a painful procedure that may induce hypertension, tachycardia, and other undesirable hemodynamic disorders. Although premature neonates are very sensitive to pain and vulnerable to its long-term effects, the need for sedation before tracheal intubation is still discussed in neonatal units. Our objective was to investigate the practice of premedication before tracheal intubation in neonatal and pediatric units and determine the influence of premedication on intubating conditions.

DESIGN

We performed a 10-day prospective survey in 75 neonatal and pediatric intensive care units among the 98 licensed in France. A questionnaire was completed for each intubation performed in each surveyed unit.

SUBJECTS

A total of 204 patients were studied: 140 neonates, 52 infants, and 12 children.

MAIN RESULTS

Data on 204 tracheal intubations were collected from 223 that were performed during the study period (participation rate, 91.4%). Premedication was used before intubation for 37.1%, 67.3%, and 91.7% of neonates, infants, and children, respectively (p <.0001). In the subgroup of neonates, premedication was particularly rare for the youngest and the smallest infants. Midazolam was the principle hypnotic used in neonates, whereas propofol was mainly used in children. Opioids or muscle relaxants were used in 16.2% and 4.4% of the patients, respectively. A low success rate and a high incidence of hypoxemia and bradycardia were correlated with the inexperience of the operator. Premedication did not significantly influence either the success rate or the undesirable events associated with tracheal intubation.

CONCLUSION

Use of premedication before tracheal intubation is limited in neonates and increases according to the age of the patient. Midazolam does not seem to be an accurate choice to improve intubating conditions in neonates and infants. Because tracheal intubation is a technique that requires a skill only developed by regular practice, operators who have limited experience with intubating children should be supported by senior operators.

Critères de choix du matériel d’intubation chez l’enfant

The differences between a child's airway and an adult's, dictate differences in anaesthetic management techniques. Techniques and principles to assist in this management are reviewed in this article. Paediatric specificities of airway devices and other materials required for endotracheal intubation are described. In addition, recent development of equipment and current trends in management of paediatric airway are discussed.

Laryngotracheo-oesophageal cleft in an infant: airway management during bronchoscopy

A case of laryngotracheo-oesophageal cleft scheduled for bronchoscopy and repair is described. The authors highlight the difficulties of bronchoscopy in such a patient and suggest simple manoeuvres to negotiate the rigid bronchoscope into the trachea.