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Solanki S, Dogra S, Gupta PK, Peters NJ, Malik MA, Mahajan JK. Randomized controlled trial to evaluate the rate of successful neonatal endotracheal intubation performed with a stylet versus without a stylet. Paediatr Anaesth 2024; 34:448-453. [PMID: 38305632 DOI: 10.1111/pan.14845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/20/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Neonates in intensive care units often require endotracheal intubation and mechanical ventilation. During this intubation procedure, a stylet is frequently used along with an endotracheal tube. Despite the widespread use of a stylet, it is still not known whether its use increases the intubation success rate. This study examined the association between stylet use and the intubation success rate in surgical neonates. METHODOLOGY This single-center study was conducted between December 2021 and December 2022 in the Neonatal surgical intensive care unit of a tertiary care center in Northern India. Infants were randomized to have the endotracheal intubation procedure performed using either an endotracheal tube alone or with a stylet. The primary outcome of the study was to assess the successful first-attempt neonatal endotracheal intubation rate with and without using a stylet. Apart from the rate of successful intubation, the duration of the intubation and complications during the intubation procedures as measured by bradycardia, desaturation episodes, and local trauma were also recorded. Both groups were thus compared on above mentioned outcomes. RESULTS The total number of neonates enrolled were 200, and the overall success rate (81% in the stylet group vs. 73% in the non-stylet group) was not statistically significant. Intubation time was however less, when stylet was used (16.2 ± 4.3 vs. 17.5 ± 5.0 s, p = .046). When the endotracheal tube size was 3 or less, the success rate was substantially higher in the stylet group (80%) than the non-stylet group (63%), p = .03. No statistical difference was recorded for bleeding and local trauma, though the esophageal intubation rate was higher when intubation was attempted without the stylet. CONCLUSION Endotracheal intubation using a stylet did not significantly improve the success rate of the procedure, however, intubation time significantly varied between groups and in different conditions. The rigidity and curvature provided by the stylet may facilitate the process of intubation when smaller caliber endotracheal tubes are used.
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Affiliation(s)
| | - Shivani Dogra
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - Pramod K Gupta
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - Nitin J Peters
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - Muneer A Malik
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - J K Mahajan
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
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Ali MA, Raju MP, Miller G, Vora N, Beeram M, Raju V, Shetty A, Govande V, Nguyen N, Chiruvolu A. Pre-Medications for Non-Emergency Tracheal Intubation in the United States Neonatal Intensive Care Units. Cureus 2024; 16:e53512. [PMID: 38440038 PMCID: PMC10911687 DOI: 10.7759/cureus.53512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Premedication in neonates undergoing elective intubation effectively minimizes the negative physiological events of bradycardia, systemic hypertension, intracranial hypertension, and hypoxia. Premedication decreases procedure-related pain and discomfort. This study aimed to evaluate the current practice of pre-intubation medications for non-emergent intubations in preterm and term neonates in the United States. STUDY DESIGN A cross-sectional survey (Appendix) was sent via e-mail to all level 3 and 4 Neonatal Intensive Care Units (NICUs) of the Organization of Neonatal Perinatal Medicine Training Program Directors (ONTPD), NICU directors with pediatric residency only, and Baylor Scott and White Health, Mednax, and Envision health services systems. RESULTS Of 170 responses, 41% (69/168) routinely premedicate, 38% (64/168) premedicate under specific circumstances, and 21% (35/168) do not administer any routine pre-intubation medications. Only 46% (77/168) of units had a written policy. The most frequently used drugs were fentanyl (68%, 116/170), atropine (39%, 66/170), midazolam (38%, 64/170), and morphine (26%, 45/170). 21% (36/170) used a two-drug combination, and 38% (64/170) used a three-drug combination. The most commonly used two-drug combination was atropine and fentanyl, and the most common three-drug combination was atropine, fentanyl, and a paralytic agent. CONCLUSION Despite the well-documented benefits of premedication for NICU intubations, as aligned with AAP recommendations, the US lags behind other nations, with stagnant rates since 2006. This disparity persists despite a rise in written policies, which exhibit significant content variations. The authors advocate for the adoption of standardized, AAP-aligned policies across all NICUs in the US. Continued research is vital to monitor the progress of this crucial practice and address any underlying barriers to implementation.
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Affiliation(s)
- Mahmoud A Ali
- Pediatrics/Neonatology, West Virginia University, Morgantown, USA
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Greg Miller
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Niraj Vora
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Venkata Raju
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Ashith Shetty
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Nguyen Nguyen
- Pediatrics, Baylor Scott & White Health, Temple, USA
| | - Arpitha Chiruvolu
- Neonatology, Baylor University Medical Center, Dallas, USA
- Neonatology, Pediatrix Medical Group, Dallas, USA
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Neches SK, DeMartino C, Shay R. Pharmacologic Adjuncts for Neonatal Tracheal Intubation: The Evidence Behind Premedication. Neoreviews 2023; 24:e783-e796. [PMID: 38036442 DOI: 10.1542/neo.24-12-e783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Premedication such as analgesia, sedation, vagolytics, and paralytics may improve neonatal tracheal intubation success, reduce intubation-associated adverse events, and create optimal conditions for performing this high-risk and challenging procedure. Although rapid sequence induction including a paralytic agent has been adopted for intubations in pediatric and adult critical care, neonatal clinical practice varies. This review aims to summarize details of common classes of neonatal intubation premedication including indications for use, medication route, dosage, potential adverse effects in term and preterm infants, and reversal agents. In addition, this review shares the literature on national and international practice variations; explores evidence in support of establishing premedication guidelines; and discusses unique circumstances in which premedication use has not been established, such as during catheter-based or minimally invasive surfactant delivery. With increasing survival of extremely preterm infants, clear guidance for premedication use in this population will be necessary, particularly considering potential short- and long-term side effects of procedural sedation on the developing brain.
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Affiliation(s)
- Sara K Neches
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Cassandra DeMartino
- Department of Pediatrics, Division of Neonatology, Yale New Haven Hospital, New Haven, CT
| | - Rebecca Shay
- Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine and Children's Hospital of Colorado, Denver, CO
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Mimoglu E, Joyce K, Mohamed B, Sathiyamurthy S, Banerjee J. Variability of neonatal premedication practices for endotracheal intubation and LISA in the UK (NeoPRINT survey). Early Hum Dev 2023; 183:105808. [PMID: 37343322 DOI: 10.1016/j.earlhumdev.2023.105808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE The NeoPRINT Survey was designed to assess premedication practices throughout UK NHS Trusts for both neonatal endotracheal intubation and less invasive surfactant administration (LISA). DESIGN An online survey consisting of multiple choice and open answer questions covering preferences of premedication for endotracheal intubation and LISA was distributed over a 67-day period. Responses were then analysed using STATA IC 16.0. SETTING Online survey distributed to all UK Neonatal Units (NNUs). PARTICIPANTS The survey evaluated premedication practices for endotracheal intubation and LISA in neonates requiring these procedures. MAIN OUTCOME MEASURES The use of different premedication categories as well as individual medications within each category was analysed to create a picture of typical clinical practice across the UK. RESULTS The response rate for the survey was 40.8 % (78/191). Premedication was used in all hospitals for endotracheal intubation but overall, 50 % (39/78) of the units that have responded, use premedications for LISA. Individual clinician preference had an impact on premedication practices within each NNU. CONCLUSION The wide variability on first-line premedication for endotracheal intubation noted in this survey could be overcome using best available evidence through consensus guidance driven by organisations such as British Association of Perinatal |Medicine (BAPM). Secondly, the divisive view around LISA premedication practices noted in this survey requires an answer through a randomised controlled trial.
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Affiliation(s)
- Ecem Mimoglu
- School of Medicine, Imperial College London, London, UK
| | - Katie Joyce
- School of Medicine, Imperial College London, London, UK
| | - Basma Mohamed
- St George's University Hospitals NHS Foundation Trust, London, UK; Department of Neonatology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Jay Banerjee
- Department of Neonatology, Imperial College Healthcare NHS Trust, London, UK; Institute of Reproductive and Developmental Biology, Imperial College London, Biomedical Research Centre, Imperial College Healthcare NHS Trust, London, UK; Centre for Paediatrics and Child Health, Imperial College London, London, UK.
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Neches SK, Brei BK, Umoren R, Gray MM, Nishisaki A, Foglia EE, Sawyer T. Association of full premedication on tracheal intubation outcomes in the neonatal intensive care unit: an observational cohort study. J Perinatol 2023; 43:1007-1014. [PMID: 36801956 DOI: 10.1038/s41372-023-01632-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/20/2023]
Abstract
OBJECTIVE Evaluate the association of short-term tracheal intubation (TI) outcomes with premedication in the NICU. STUDY DESIGN Observational single-center cohort study comparing TIs with full premedication (opiate analgesia and vagolytic and paralytic), partial premedication, and no premedication. The primary outcome is adverse TI associated events (TIAEs) in intubations with full premedication compared to those with partial or no premedication. Secondary outcomes included change in heart rate and first attempt TI success. RESULTS 352 encounters in 253 infants (median gestation 28 weeks, birth weight 1100 g) were analyzed. TI with full premedication was associated with fewer TIAEs aOR 0.26 (95%CI 0.1-0.6) compared with no premedication, and higher first attempt success aOR 2.7 (95%CI 1.3-4.5) compared with partial premedication after adjusting for patient and provider characteristics. CONCLUSION The use of full premedication for neonatal TI, including an opiate, vagolytic, and paralytic, is associated with fewer adverse events compared with no and partial premedication.
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Affiliation(s)
- Sara K Neches
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA.
| | - Brianna K Brei
- University of Nebraska Medical Center, Department of Pediatrics, Division of Neonatology, Omaha, NE, USA
| | - Rachel Umoren
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
| | - Megan M Gray
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
| | - Akira Nishisaki
- Children's Hospital of Philadelphia. Department of Anesthesiology and Critical Care Medicine, Philadelphia, PA, USA
| | - Elizabeth E Foglia
- Children's Hospital of Philadelphia. Department of Pediatrics, Division of Neonatology, Philadelphia, PA, USA
| | - Taylor Sawyer
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
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Debay A, Patel S, Wintermark P, Claveau M, Olivier F, Beltempo M. Association of Delivery Room and Neonatal Intensive Care Unit Intubation, and Number of Tracheal Intubation Attempts with Death or Severe Neurological Injury among Preterm Infants. Am J Perinatol 2022; 39:776-785. [PMID: 33075843 DOI: 10.1055/s-0040-1718577] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The study aimed to assess the association of tracheal intubation (TI) and where it is performed, and the number of TI attempts with death and/or severe neurological injury (SNI) among preterm infants. STUDY DESIGN Retrospective cohort study of infants born 23 to 32 weeks, admitted to a single level-3 neonatal intensive care unit (NICU) between 2015 and 2018. Exposures were location of TI (delivery room [DR] vs. NICU) and number of TI attempts (1 vs. >1). Primary outcome was death and/or SNI (intraventricular hemorrhage grade 3-4 and/or periventricular leukomalacia). Multivariable logistic regression analysis was used to assess association between exposures and outcomes and to adjust for confounders. RESULTS Rate of death and/or SNI was 2.5% (6/240) among infants never intubated, 12% (13/105) among NICU TI, 32% (31/97) among DR TI, 20% (17/85) among infants with one TI attempt and 23% (27/117) among infants with >1 TI attempt. Overall, median number of TI attempts was 1 (interquartile range [IQR]: 1-2). Compared with no TI, DR TI (adjusted odds ratio [AOR]: 9.04, 95% confidence interval [CI]: 3.21-28.84) and NICU TI (AOR: 3.42, 95% CI: 1.21-10.61) were associated with higher odds of death and/or SNI. The DR TI was associated with higher odds of death and/or SNI compared with NICU TI (AOR: 2.64, 95% CI: 1.17-6.22). The number of intubation attempts (1 vs. >1) was not associated with death and/or SNI (AOR: 0.95, 95% CI: 0.47-2.03). CONCLUSION The DR TI is associated with higher odds of death and/or SNI compared with NICU TI, and may help identify higher risk infants. There was no association between the number of TI attempts and death and/or SNI. KEY POINTS · Delivery room intubation correlates with morbidity.. · Less than 2 intubation attempts are not associated with IVH.. · Provider training reduces intubation attempts..
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Affiliation(s)
- Anthony Debay
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Sharina Patel
- McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | - Pia Wintermark
- McGill University Health Center Research Institute, Montreal, Quebec, Canada.,Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - Martine Claveau
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - François Olivier
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - Marc Beltempo
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
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Tribolet S, Hennuy N, Snyers D, Lefèbvre C, Rigo V. Analgosedation before Less-Invasive Surfactant Administration: A Systematic Review. Neonatology 2022; 119:137-150. [PMID: 35124678 DOI: 10.1159/000521553] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 12/12/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Sophie Tribolet
- Neonatology Division, University Hospital of Liège, Liège, Belgium
| | - Nadège Hennuy
- Neonatology Division, University Hospital of Liège, Liège, Belgium
| | - Diane Snyers
- Neonatology Division, University Hospital of Liège, Liège, Belgium
| | | | - Vincent Rigo
- Neonatology Division, University Hospital of Liège, Liège, Belgium
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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.
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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
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9
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Stimulating and maintaining spontaneous breathing during transition of preterm infants. Pediatr Res 2021; 90:722-730. [PMID: 31216570 DOI: 10.1038/s41390-019-0468-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/25/2019] [Accepted: 06/03/2019] [Indexed: 01/30/2023]
Abstract
Most preterm infants breathe at birth, but need additional respiratory support due to immaturity of the lung and respiratory control mechanisms. To avoid lung injury, the focus of respiratory support has shifted from invasive towards non-invasive ventilation. However, applying effective non-invasive ventilation is difficult due to mask leak and airway obstruction. The larynx has been overlooked as one of the causes for obstruction, preventing face mask ventilation from inflating the lung. The larynx remains mostly closed at birth, only opening briefly during a spontaneous breath. Stimulating and supporting spontaneous breathing could enhance the success of non-invasive ventilation by ensuring that the larynx remains open. Maintaining adequate spontaneous breathing and thereby reducing the need for invasive ventilation is not only important directly after birth, but also in the first hours after admission to the NICU. Respiratory distress syndrome is an important cause of respiratory failure. Traditionally, treatment of RDS required intubation and mechanical ventilation to administer exogenous surfactant. However, new ways have been implemented to administer surfactant and preserve spontaneous breathing while maintaining non-invasive support. In this narrative review we aim to describe interventions focused on stimulation and maintenance of spontaneous breathing of preterm infants in the first hours after birth.
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10
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Glenn T, Sudhakar S, Markowski A, Malay S, Hibbs AM. Patient characteristics associated with complications during neonatal intubations. Pediatr Pulmonol 2021; 56:2576-2582. [PMID: 33983688 PMCID: PMC8298275 DOI: 10.1002/ppul.25453] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/21/2021] [Accepted: 04/30/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Complications of neonatal intubation are known to be increased with emergent intubations, increased number of attempts, unstable hemodynamics, or ventilation failure; and decreased with use of paralytic medication and videolaryngoscopy. Patient characteristics associated with complications are not well understood. DESIGN/METHODS A retrospective cohort study was performed of neonates who underwent intubation between January 2017 and June 2019. Patient characteristics of infants with and without complications were compared. Complications included common adverse events and abnormal vital sign changes occurring during intubation. RESULTS A total of 467 intubation encounters in 352 infants were included with median gestational age (GA) at birth of 29 weeks, postmenstrual age (PMA) 33 weeks at intubation, and median weight 1795 g. 41.5% of infants had complications and 58.5% of infants did not. Infants with complications compared to infants without had a median FiO2 of 0.50 versus 0.45 (p = .183), median GA at birth of 29 versus 31 weeks (p < .001), median PMA of 32 weeks versus 33.0 weeks (p = .352), median weight of 1540 g versus 1970g (p = .091), and median chronological age of 3 days versus 1 day (p = .001). Generalized Estimating Equations controlling for administration of paralytic indicated decreased complications in infants ≤21.5 days in chronological age (OR, 0.45; 95% CI, 0.30-0.69) and increased complications in infants ≤1565 g (OR, 1.52; 95% CI, 1.04-2.23). CONCLUSION Patient characteristics associated with an increased rate of complications included chronological age and weight. Further study is needed to reduce complications.
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Affiliation(s)
- Tara Glenn
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Shwetha Sudhakar
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ashley Markowski
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Sindhoosha Malay
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Anna Maria Hibbs
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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11
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DeKoninck PLJ, Horn-Oudshoorn EJJ, Knol R, Crossley KJ, Reiss IKM. Knowledge Gaps in the Fetal to Neonatal Transition of Infants With a Congenital Diaphragmatic Hernia. Front Pediatr 2021; 9:784810. [PMID: 34970518 PMCID: PMC8712749 DOI: 10.3389/fped.2021.784810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Clinical research for infants born with a congenital diaphragmatic hernia (CDH) has until recently mainly focused on advances in prenatal and postnatal treatment. However, during the early perinatal transition period there are major physiological adaptations. For most infants these changes will happen uneventfully, but for CDH infants this marks the beginning of serious respiratory complications. In recent years, there is emerging evidence that the clinical management during the perinatal stabilization period in the delivery room may influence postnatal outcomes. Herein, we discuss major knowledge gaps and novel concepts that aim to optimize fetal to neonatal transition for infants with CDH. One such novel and interesting approach is performing resuscitation with an intact umbilical cord, the efficacy of this procedure is currently being investigated in several clinical trials. Furthermore, close evaluation of neonatal physiological parameters in the first 24 h of life might provide early clues concerning the severity of lung hypoplasia and the risk of adverse outcomes. We will provide an overview of trending concepts and discuss potential areas for future research.
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Affiliation(s)
- Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Division Fetal Medicine, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Emily J J Horn-Oudshoorn
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Ronny Knol
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
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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.
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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
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13
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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.
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Affiliation(s)
| | | | - Elaine M. Boyle
- Department of Health Sciences University of Leicester Leicester UK
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14
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De Luca D, Shankar-Aguilera S, Centorrino R, Fortas F, Yousef N, Carnielli VP. Less invasive surfactant administration: a word of caution. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:331-340. [PMID: 32014122 DOI: 10.1016/s2352-4642(19)30405-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/17/2019] [Accepted: 11/05/2019] [Indexed: 12/13/2022]
Abstract
Surfactant is a cornerstone of neonatal critical care, and the presumed less (or minimally) invasive techniques for its administration have been proposed to reduce invasiveness of neonatal critical care interventions. These techniques are generally known as less invasive surfactant administration (LISA) and have quickly gained popularity in some neonatal intensive care units. Despite the increase in the use of LISA, we believe that the pathobiological background supporting its possible clinical benefits is unclear. Similarly, it is unclear whether there are any ignored drawbacks, as LISA has been tested in only a few trials and some physiopathological issues seem to have gone unnoticed. Active research is warranted to fill these knowledge gaps before LISA can be firmly recommended. In this Viewpoint, we provide an in-depth analysis of LISA techniques, based on physiological and pathobiological factors, followed by a critical appraisal of available clinical data, and highlight some possible future research directions.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Antoine Béclère Medical Center, APHP, South Paris University Hospitals, Paris, France; Physiopathology and Therapeutic Innovation Unit-U999, South Paris-Saclay University, Paris, France.
| | - Shivani Shankar-Aguilera
- Division of Pediatrics and Neonatal Critical Care, Antoine Béclère Medical Center, APHP, South Paris University Hospitals, Paris, France
| | - Roberta Centorrino
- Division of Pediatrics and Neonatal Critical Care, Antoine Béclère Medical Center, APHP, South Paris University Hospitals, Paris, France; Physiopathology and Therapeutic Innovation Unit-U999, South Paris-Saclay University, Paris, France
| | - Feriel Fortas
- Division of Pediatrics and Neonatal Critical Care, Antoine Béclère Medical Center, APHP, South Paris University Hospitals, Paris, France; Physiopathology and Therapeutic Innovation Unit-U999, South Paris-Saclay University, Paris, France
| | - Nadya Yousef
- Division of Pediatrics and Neonatal Critical Care, Antoine Béclère Medical Center, APHP, South Paris University Hospitals, Paris, France
| | - Virgilio P Carnielli
- Division of Neonatology, G Salesi Women and Children's Hospital, Polytechnical University of Marche, Ancona, Italy
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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.
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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
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Abstract
Safe and effective airway management of neonates requires unique knowledge and clinical skills. Practitioners should have an understanding of neonatal airway anatomy and respiratory physiology and their clinical implications related to airway management. It is vital to recognize the potential sequelae of prematurity. Clinicians should be familiar with the skills and techniques available for managing normal neonatal airways. This review provides stepwise considerations for managing the neonatal airway: specific considerations for neonatal airway management, assessment and preparation, induction and premedication, and techniques and strategies for airway management in patients with normal anatomy and in patients who are difficult to intubate.
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Affiliation(s)
- Raymond S Park
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - James M Peyton
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Pete G Kovatsis
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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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.
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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
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Merali HS, Tessaro MO, Ali KQ, Morris SK, Soofi SB, Ariff S. A novel training simulator for portable ultrasound identification of incorrect newborn endotracheal tube placement - observational diagnostic accuracy study protocol. BMC Pediatr 2019; 19:434. [PMID: 31722685 PMCID: PMC6852924 DOI: 10.1186/s12887-019-1717-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/12/2019] [Indexed: 12/14/2022] Open
Abstract
Background Endotracheal tube (ETT) placement is a critical procedure for newborns that are unable to breathe. Inadvertent esophageal intubation can lead to oxygen deprivation and consequent permanent neurological impairment. Current standard-of-care methods to confirm ETT placement in neonates (auscultation, colorimetric capnography, and chest x-ray) are time consuming or unreliable, especially in the stressful resuscitation environment. Point-of-care ultrasound (POCUS) of the neck has recently emerged as a powerful tool for detecting esophageal ETTs. It is accurate and fast, and is also easy to learn and perform, especially on children. Methods This will be an observational diagnostic accuracy study consisting of two phases and conducted at the Aga Khan University Hospital in Karachi, Pakistan. In phase 1, neonatal health care providers that currently perform standard-of-care methods for ETT localization, regardless of experience in portable ultrasound, will undergo a two-hour training session. During this session, providers will learn to detect tracheal vs. esophageal ETTs using POCUS. The session will consist of a didactic component, hands-on training with a novel intubation ultrasound simulator, and practice with stable, ventilated newborns. At the end of the session, the providers will undergo an objective structured assessment of technical skills, as well as an evaluation of their ability to differentiate between tracheal and esophageal endotracheal tubes. In phase 2, newborns requiring intubation will be assessed for ETT location via POCUS, at the same time as standard-of-care methods. The initial 2 months of phase 2 will include a quality assurance component to ensure the POCUS accuracy of trained providers. The primary outcome of the study is to determine the accuracy of neck POCUS for ETT location when performed by neonatal providers with focused POCUS training, and the secondary outcome is to determine whether neck POCUS is faster than standard-of-care methods. Discussion This study represents the first large investigation of the benefits of POCUS for ETT confirmation in the sickest newborns undergoing intubations for respiratory support. Trial registration ClinicalTrials.gov Identifier: NCT03533218. Registered May 2018.
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Affiliation(s)
- Hasan S Merali
- Division of Pediatric Emergency Medicine, McMaster Children's Hospital, McMaster University, 1280 Main Street West, HSC-2R104, Hamilton, ON, L8S 4K1, Canada
| | - Mark O Tessaro
- Division of Pediatric Emergency Medicine, Emergency Point-of-Care Ultrasound Program, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Khushboo Q Ali
- Department of Paediatrics & Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Shaun K Morris
- Division of Infectious Diseases and Centre for Global Child Health, Hospital for Sick Children, Department of Pediatrics Faculty of Medicine, 555 University Avenue, Toronto, ON, M5G1X8, Canada
| | - Sajid B Soofi
- Department of Paediatrics & Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Shabina Ariff
- Department of Paediatrics & Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan.
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Decreasing Time from Decision to Intubation in Premedicated Neonates: A Quality Improvement Initiative. Pediatr Qual Saf 2019; 4:e234. [PMID: 32010860 PMCID: PMC6946237 DOI: 10.1097/pq9.0000000000000234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/18/2019] [Indexed: 12/27/2022] Open
Abstract
Endotracheal intubation carries the risk of discomfort, decompensation, oral trauma, and endotracheal tube malposition. Treatment with premedications reduces complications, increases overall intubation safety, improves pain control, and improves first-pass success. However, time is frequently a barrier to administration. We aimed to decrease the decision-to-intubation time interval from a baseline of 40 minutes to less than 35 minutes over 6 months.
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20
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Borrhomée S, Merbouche S, Kern-Duciau N, Boize P. Umbilical vein catheterization through Wharton's jelly: A possibility for a fast and safe way to deliver treatments in the delivery room? Arch Pediatr 2019; 26:381-384. [PMID: 31285106 DOI: 10.1016/j.arcped.2019.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/02/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Abstract
Fast and safe venous access can be a critical issue in the delivery room during neonatal cardiopulmonary resuscitation or before endotracheal intubation. Here, we describe a new method to inject drugs using the umbilical vein, directly punctured through Wharton's jelly, performed in ten newborns between November 2016 and May 2018. The umbilical vein was identified and punctured easily and a reflux was obtained in all patients. The treatments were efficient in all but two patients, which was imputable to the method in one patient. We describe a new route for administration of drugs that has been successfully used in neonates.
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Affiliation(s)
- S Borrhomée
- Neonatal Intensive Care Unit of Pontoise, Hospital René-Dubos, 6, avenue de l'Île-de-France, 95300 Pontoise, France.
| | - S Merbouche
- Neonatal Intensive Care Unit of Pontoise, Hospital René-Dubos, 6, avenue de l'Île-de-France, 95300 Pontoise, France
| | - N Kern-Duciau
- Neonatal Intensive Care Unit of Pontoise, Hospital René-Dubos, 6, avenue de l'Île-de-France, 95300 Pontoise, France
| | - P Boize
- Neonatal Intensive Care Unit of Pontoise, Hospital René-Dubos, 6, avenue de l'Île-de-France, 95300 Pontoise, France
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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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Calevo MG, Veronese N, Cavallin F, Paola C, Micaglio M, Trevisanuto D. Supraglottic airway devices for surfactant treatment: systematic review and meta-analysis. J Perinatol 2019; 39:173-183. [PMID: 30518796 DOI: 10.1038/s41372-018-0281-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/26/2018] [Accepted: 10/24/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare surfactant administration via supraglottic airway device (SAD) vs. nasal CPAP alone or INSURE. STUDY DESIGN A systematic search of PubMed, EMBASE, SCOPUS, Cochrane Central Register of Controlled Trials and Clinicaltrials.gov was performed. Articles meeting inclusion criteria (RCT, surfactant administration via SAD, laryngeal mask, I-gel) were assessed RESULTS: Five RCTs were eligible. Surfactant administration via SAD reduced the need for intubation/mechanical ventilation (RR 0.57, 95%CI 0.38-0.85) and short-term oxygen requirements (MD -8.00, 95%CI -11.09 to -4.91) compared to nCPAP alone. Surfactant administration via SAD reduced the need for intubation/mechanical ventilation (RR 0.43, 95%CI 0.31-0.61), but increased short-term oxygen requirements (MD 3.10, 95%CI 0.51-5.69) compared to INSURE approach. CONCLUSIONS In preterm infants with RDS, surfactant administration via SAD reduces the need for intubation/mechanical ventilation. Overall, available literature includes few, small, poor-quality studies. Surfactant administration via SAD should be limited to clinical trials.
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Affiliation(s)
- Maria Grazia Calevo
- Epidemiology, Biostatistics and Committees Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Nicola Veronese
- National Research Council, Neuroscience Institute, Aging Branch, Padua, Italy
| | | | | | - Massimo Micaglio
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy.
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de Kort EHM, Andriessen P, Reiss IKH, van Dijk M, Simons SHP. Evaluation of an Intubation Readiness Score to Assess Neonatal Sedation before Intubation. Neonatology 2019; 115:43-48. [PMID: 30278443 DOI: 10.1159/000492711] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/07/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Premedication for neonatal intubation facilitates the procedure and reduces stress and physiological disturbances. However, no validated scoring system to assess the effect of premedication prior to intubation is available. OBJECTIVE To evaluate the usefulness of an Intubation Readiness Score (IRS) to assess the effect of premedication prior to intubation in newborn infants. METHODS Two-center prospective study in neonates who needed endotracheal intubation. Intubation was performed using a standardized procedure with propofol 1-2 mg/kg as premedication. The level of sedation was assessed with the IRS by evaluating the motor response to a firm stimulus (1 = spontaneous movement; 2 = movement on slight touch; 3 = movement on firm stimulus; 4 = no movement). Intubation was proceeded if an adequate effect, defined as an IRS of 3 or 4, was reached. IRS was compared to the quality of intubation measured with the Viby-Mogensen intubation score. RESULTS A total of 115 patients, with a median gestational age of 27.7 weeks (interquartile range 5.3) and a median birth weight of 1,005 g (interquartile range 940), were included. An adequate IRS was achieved in 105 patients, 89 (85%) of whom also had a good Viby-Mogensen intubation score and 16 (15%) had an inadequate Viby-Mogensen intubation score. The positive predictive value of the IRS was 85%. CONCLUSIONS Preintubation sedation assessment using the IRS can adequately predict optimal conditions during intubation in the majority of neonates. We suggest using the IRS in routine clinical care. Further research combining the IRS with other parameters could further improve the predictability of adequate sedation during intubation.
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Affiliation(s)
- Ellen H M de Kort
- Department of Neonatology, Máxima Medical Center, Veldhoven, The .,Division of Neonatology, Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The
| | - Peter Andriessen
- Department of Neonatology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Irwin K H Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique van Dijk
- Division of Neonatology, Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
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Sgrò S, Morini F, Bozza P, Piersigilli F, Bagolan P, Picardo S. Intravenous Propofol Allows Fast Intubation in Neonates and Young Infants Undergoing Major Surgery. Front Pediatr 2019; 7:321. [PMID: 31475123 PMCID: PMC6702265 DOI: 10.3389/fped.2019.00321] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 07/16/2019] [Indexed: 11/18/2022] Open
Abstract
Aim of the study: In selected surgical neonates and infants, the rapidity of induction and intubation may represent an important factor for their safety. Propofol is an anesthetic characterized by a rapid onset and fast recovery time that may reduce time of anesthetic induction and improve post-anesthetic outcome. The aim of this study was to evaluate the safety and efficacy of anesthesia induction in full-term neonates and young infants after propofol bolus administration. Methods: A retrospective case-control study including infants below 6 months of age, undergoing general anesthesia between 2011 and 2013, was carried out. Patients that received intravenous propofol bolus to induce anesthesia were compared to patients who received inhaled sevoflurane. Time to reach successful orotracheal intubation (OTI) was measured in seconds. The quality of OTI was defined as "excellent," "good," and "poor," based on established classification and was reported. Hemodynamic parameters as systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), heart rate (HR), and oxygen saturation (SaO2) were collected before OTI (t0), at OTI (t1), and at spontaneous breathing recovery (t2). Main adverse effects were recorded for both groups. Results are median (IQ range) or prevalence; p < 0.05 was considered significant. Results: 160 infants were enrolled in the study, 80 received propofol and 80 inhaled sevoflurane. Major surgery (involving organs in the thoracic, abdominal, or pelvic cavities) was performed in 64 and 54% of patients in the propofol and sevoflurane group, respectively (p = 0.07). Patients in the propofol group showed a shorter time for OTI [11.5 (4.0-65) vs. 360.0 (228.0-720.0) seconds, (p < 0.0001)]. No difference was found in the quality of OTI between the two groups. No significant complications were recorded in either group. Conclusions: Propofol is a safe and effective anesthetic in neonates and infants permitting rapid induction of anesthesia and rapid intubation, without negative impact on the quality of intubation and haemodynamic compromise.
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Affiliation(s)
- Stefania Sgrò
- Department of Anesthesia and Critical Care, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Francesco Morini
- Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Patrizia Bozza
- Department of Anesthesia and Critical Care, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Fiammetta Piersigilli
- Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Sergio Picardo
- Department of Anesthesia and Critical Care, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
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25
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Krick J, Gray M, Umoren R, Lee G, Sawyer T. Premedication with paralysis improves intubation success and decreases adverse events in very low birth weight infants: a prospective cohort study. J Perinatol 2018; 38:681-686. [PMID: 29467520 DOI: 10.1038/s41372-018-0082-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 01/20/2018] [Accepted: 01/29/2018] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Jeanne Krick
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA.
| | - Megan Gray
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - Rachel Umoren
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - Gina Lee
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - Taylor Sawyer
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
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26
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Moving from controversy to consensus: premedication for neonatal intubation. J Perinatol 2018; 38:611-613. [PMID: 29930326 DOI: 10.1038/s41372-018-0115-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 03/12/2018] [Indexed: 12/23/2022]
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27
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Flint RB, van Beek F, Andriessen P, Zimmermann LJ, Liem KD, Reiss IKM, de Groot R, Tibboel D, Burger DM, Simons SHP. Large differences in neonatal drug use between NICUs are common practice: time for consensus? Br J Clin Pharmacol 2018; 84:1313-1323. [PMID: 29624207 PMCID: PMC5980600 DOI: 10.1111/bcp.13563] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/24/2018] [Accepted: 02/11/2018] [Indexed: 01/27/2023] Open
Abstract
Aims Evidence for drug use in newborns is sparse, which may cause large differences in drug prescriptions. We aimed to investigate the differences between neonatal intensive care units (NICUs) in the Netherlands in currently prescribed drugs. Methods This multicentre study included neonates admitted during 12 months to four different NICUs. Drugs were classified in accordance with the Anatomical Therapeutic Chemical (ATC) classification system and assessed for on/off‐label status in relation to neonatal age. The treatment protocols for four common indications for drug use were compared: pain, intubation, convulsions and hypotension. Results A total of 1491 neonates (GA range 23+6–42+2 weeks) were included with a total of 32 182 patient days, 181 different drugs and 10 895 prescriptions of which 23% was off‐label in relation to neonatal age. Overall, anti‐infective drugs were most frequently used with a total of 3161 prescriptions, of which 4% was off‐label in relation to neonatal age. Nervous system drugs included 2500 prescriptions of which 31% was off‐label in relation to neonatal age. Nervous system drugs, blood and blood forming organs, and cardiovascular drugs showed the largest differences between NICUs with ranges of 919–2278, 554–1465, and 238–952 total prescriptions per 1000 patients per ATC class, respectively. Conclusions We showed that drug use varies widely in neonatal clinical practice. The drug classes with the highest proportion of off‐label drugs in relation to neonatal age showed the largest differences between NICUs, i.e. cardiovascular and nervous system drugs. Drug research in neonates should receive high priority to guarantee safe and appropriate medicines and optimal treatment.
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Affiliation(s)
- Robert B Flint
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pharmacy and Radboud Institute of Health Sciences (RIHS), Radboudumc, Nijmegen, The Netherlands.,Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Floor van Beek
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Peter Andriessen
- Department of Pediatrics, Division of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Luc J Zimmermann
- Department of Pediatrics, Maastricht University Medical Center, School of Oncology and Developmental Biology, School of Mental Health and Neuroscience, Maastricht, The Netherlands
| | - Kian D Liem
- Department of Pediatrics, Division of Neonatology, Radboudumc, Nijmegen, Nijmegen, The Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ronald de Groot
- Laboratory of Pediatric Infectious Diseases, Department of Pediatrics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Department of Pediatrics, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - David M Burger
- Department of Pharmacy and Radboud Institute of Health Sciences (RIHS), Radboudumc, Nijmegen, The Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
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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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29
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de Kort EHM, Halbmeijer NM, Reiss IKM, Simons SHP. Assessment of sedation level prior to neonatal intubation: A systematic review. Paediatr Anaesth 2018; 28:28-36. [PMID: 29159860 DOI: 10.1111/pan.13285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Adequate premedication before neonatal endotracheal intubation reduces pain, stress, and adverse physiological responses, diminishes duration and number of attempts at intubation, and prevents traumatic airway injury. Therefore, intubation should not be started until an adequate level of sedation is reached. It is not clear how this should be measured in the clinical situation. OBJECTIVES The aim of this study is to provide a systematic review of the usability and validity of scoring systems or other objective parameters to evaluate the level of sedation before intubation in neonates. Secondary aims were to describe parameters that are used to determine the level of sedation and criteria on which the decision to proceed with intubation is based. METHODS Literature was searched (January 2017) in the following electronic databases: Embase, Medline, Web of Science, Cochrane Central Registrar of Controlled Trials, Pubmed Publisher, and Google Scholar. RESULTS From 1653 hits, 20 studies were finally included in the systematic review. In 7 studies, intubation was started after a predefined time period; in 1 study, preoxygenation was the criterion to start with intubation; and in 12 studies, intubation was started in case of adequate sedation and/or relaxation. Only 4 studies described the use of 3 different objective scoring system, all in the neonatal intensive care unit, which are not validated. CONCLUSION No validated scoring systems to assess the level of sedation prior to intubation in newborns are available in the literature. Three objective sedation assessment tools seem promising but need further validation before they can be implemented in research and clinical settings.
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Affiliation(s)
- Ellen H M de Kort
- Department of Pediatrics and Neonatology, Máxima Medical Center, Veldhoven, The Netherlands.,Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nienke M Halbmeijer
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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O'Shea JE, O'Gorman J, Gupta A, Sinhal S, Foster JP, O'Connell LAF, Kamlin COF, Davis PG. Orotracheal intubation in infants performed with a stylet versus without a stylet. Cochrane Database Syst Rev 2017. [PMID: 28640930 PMCID: PMC6481391 DOI: 10.1002/14651858.cd011791.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Neonatal endotracheal intubation is a common and potentially life-saving intervention. It is a mandatory skill for neonatal trainees, but one that is difficult to master and maintain. Intubation opportunities for trainees are decreasing and success rates are subsequently falling. Use of a stylet may aid intubation and improve success. However, the potential for associated harm must be considered. OBJECTIVES To compare the benefits and harms of neonatal orotracheal intubation with a stylet versus neonatal orotracheal intubation without a stylet. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE; Embase; the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and previous reviews. We also searched cross-references, contacted expert informants, handsearched journals, and looked at conference proceedings. We searched clinical trials registries for current and recently completed trials. We conducted our most recent search in April 2017. SELECTION CRITERIA All randomised, quasi-randomised, and cluster-randomised controlled trials comparing use versus non-use of a stylet in neonatal orotracheal intubation. DATA COLLECTION AND ANALYSIS Two review authors independently assessed results of searches against predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used the standard methods of the Cochrane Collaboration, as documented in the Cochrane Handbook for Systemic Reviews of Interventions, and of the Cochrane Neonatal Review Group. MAIN RESULTS We included a single-centre non-blinded randomised controlled trial that reported a total of 302 intubation attempts in 232 infants. The median gestational age of enrolled infants was 29 weeks. Paediatric residents and fellows performed the intubations. We judged the study to be at low risk of bias overall. Investigators compared success rates of first-attempt intubation with and without use of a stylet and reported success rates as similar between stylet and no-stylet groups (57% and 53%) (P = 0.47). Success rates did not differ between groups in subgroup analyses by provider level of training and infant weight. Results showed no differences in secondary review outcomes, including duration of intubation, number of attempts, participant instability during the procedure, and local airway trauma. Only 25% of all intubations took less than 30 seconds to perform. Study authors did not report neonatal morbidity nor mortality. We considered the quality of evidence as low on GRADE analysis, given that we identified only one unblinded study. AUTHORS' CONCLUSIONS Current available evidence suggests that use of a stylet during neonatal orotracheal intubation does not significantly improve the success rate among paediatric trainees. However, only one brand of stylet and one brand of endotracheal tube have been tested, and researchers performed all intubations on infants in a hospital setting. Therefore, our results cannot be generalised beyond these limitations.
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Affiliation(s)
- Joyce E O'Shea
- Royal Hospital for ChildrenGlasgowUK
- University College CorkCorkIreland
- University of GlasgowDepartment of NeonatologyGlasgowScotlandUK
| | | | | | - Sanjay Sinhal
- Flinders Medical CentreNeonatal Intensive Care UnitFlinders DriveBedford ParkSAAustralia5042
| | - Jann P Foster
- Western Sydney UniversitySchool of Nursing and MidwiferyPenrith DCAustralia
- University of SydneyCentral Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologyCamperdownAustralia
- Ingham Research InstituteLiverpoolNSWAustralia
| | - Liam AF O'Connell
- The Royal Women's HospitalDepartment of Newborn Research132 Grattan StreetMelbourneAustralia
- Cork University Maternity HospitalCorkIreland
| | - C Omar F Kamlin
- Royal Women's HospitalNeonatal Services20 Flemington RoadParkvilleVictoriaAustraliaVIC 3052
- Murdoch Childrens Research InstituteMelbourneAustralia
| | - Peter G Davis
- Murdoch Childrens Research InstituteMelbourneAustralia
- The University of MelbourneMelbourneAustralia
- The Royal Women’s HospitalParkvilleVICAustralia3052
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de Kort EHM, Simons SHP. Reply to the Letter to the Editor "Does Remifentanil Have a Place for Sedation in the Case of Endotracheal Intubation or Minimally Invasive Surfactant Therapy in Neonates?". Neonatology 2017; 112:374-375. [PMID: 28866689 DOI: 10.1159/000479623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/20/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Ellen H M de Kort
- Department of Pediatrics and Neonatology, Máxima Medical Center, Veldhoven, The Netherlands
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32
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de Kort EHM, Hanff LM, Roofthooft D, Reiss IKM, Simons SHP. Insufficient Sedation and Severe Side Effects after Fast Administration of Remifentanil during INSURE in Preterm Newborns. Neonatology 2017; 111:172-176. [PMID: 27788524 DOI: 10.1159/000450536] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 09/02/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neonatal intubation is stressful and should be performed with premedication. In the case of an INSURE (intubation/surfactant/extubation) procedure a short duration of action of the premedication used is needed to facilitate fast extubation. Given its pharmacological profile, remifentanil seems a suitable candidate. OBJECTIVES The aim here was to evaluate the effect and side effects of remifentanil as a premedication for preterm neonates undergoing INSURE. METHODS A prospective, single-center study in a level III neonatal intensive care unit was conducted. The quality of sedation was assessed in preterm infants receiving remifentanil prior to intubation for the INSURE procedure. Intravenous remifentanil was administered quickly and followed by a saline flush in approximately 30 s. The quality of sedation was defined by a combination of adequate sedation score, good intubation conditions and absence of side effects. RESULTS The study was terminated after the inclusion of 14 patients because of the high rate of side effects and the poor intubation conditions. Adequate sedation was achieved in only 2 patients (14%). Six patients (43%) needed additional propofol to obtain adequate sedation. Chest wall rigidity occurred in 6 patients (43%). CONCLUSIONS The rapid administration of remifentanil provides insufficient sedation and is associated with a high risk of chest wall rigidity in preterm neonates.
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Affiliation(s)
- Ellen H M de Kort
- Department of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Genetic Predisposition to Poor Opioid Response in Preterm Infants: Impact of KCNJ6 and COMT Polymorphisms on Pain Relief After Endotracheal Intubation. Ther Drug Monit 2016; 38:525-33. [DOI: 10.1097/ftd.0000000000000301] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pinheiro JMB, Santana-Rivas Q, Pezzano C. Randomized trial of laryngeal mask airway versus endotracheal intubation for surfactant delivery. J Perinatol 2016; 36:196-201. [PMID: 26633145 DOI: 10.1038/jp.2015.177] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 09/01/2015] [Accepted: 10/07/2015] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare the effectiveness of surfactant delivery via endotracheal tube (ETT) using an intubation-surfactant-rapid extubation approach with premedication) vs laryngeal mask airway (LMA) in preventing the need for mechanical ventilation in preterm neonates with moderate respiratory distress syndrome (RDS). STUDY DESIGN Moderately preterm infants diagnosed with RDS, receiving nasal continuous positive airway pressure with FiO2 0.30 to 0.60, were randomized to two groups at age 3 to 48 h. Those in the ETT group were intubated following premedication with atropine and morphine, whereas the LMA group received only atropine. Both groups received calfactant before a planned reinstitution of nasal continuous positive airway pressure, and had equivalent pre-specified criteria for subsequent mechanical ventilation and surfactant retreatment. The primary outcome was failure of surfactant treatment strategy to avoid mechanical ventilation; we differentiated early from late failures to assess the contribution of potential mechanisms such as respiratory depression versus less-effective surfactant delivery. Secondary outcomes addressed efficacy and safety end points. RESULT Sixty-one patients were randomized, one excluded and 30 analyzed in each group, with similar baseline characteristics. Failure rate was 77% in the ETT group and 30% in the LMA group (P<0.001). The difference was related to early failure, as late failure rates did not differ between groups. FiO2 decrease after surfactant and rates of adverse events were similar between groups. CONCLUSION Surfactant therapy through an LMA decreases the proportion of newborns with moderate RDS who require mechanical ventilation, when compared with a standard endotracheal intubation procedure with sedation. The efficacy of surfactant in decreasing RDS severity appears similar with both methods. Morphine premedication likely contributed to early post-surfactant failures.
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Affiliation(s)
- J M B Pinheiro
- Department of Pediatrics, Albany Medical College, Albany, NY, USA
| | - Q Santana-Rivas
- Department of Pediatrics, Albany Medical College, Albany, NY, USA
| | - C Pezzano
- Department of Pediatrics, Albany Medical College, Albany, NY, USA.,Cardiorespiratory Services, Albany Medical Center, Albany, NY, USA
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Snoek KG, Reiss IKM, Greenough A, Capolupo I, Urlesberger B, Wessel L, Storme L, Deprest J, Schaible T, van Heijst A, Tibboel D. Standardized Postnatal Management of Infants with Congenital Diaphragmatic Hernia in Europe: The CDH EURO Consortium Consensus - 2015 Update. Neonatology 2016; 110:66-74. [PMID: 27077664 DOI: 10.1159/000444210] [Citation(s) in RCA: 308] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/25/2016] [Indexed: 11/19/2022]
Abstract
In 2010, the congenital diaphragmatic hernia (CDH) EURO Consortium published a standardized neonatal treatment protocol. Five years later, the number of participating centers has been raised from 13 to 22. In this article the relevant literature is updated, and consensus has been reached between the members of the CDH EURO Consortium. Key updated recommendations are: (1) planned delivery after a gestational age of 39 weeks in a high-volume tertiary center; (2) neuromuscular blocking agents to be avoided during initial treatment in the delivery room; (3) adapt treatment to reach a preductal saturation of between 80 and 95% and postductal saturation >70%; (4) target PaCO2 to be between 50 and 70 mm Hg; (5) conventional mechanical ventilation to be the optimal initial ventilation strategy, and (6) intravenous sildenafil to be considered in CDH patients with severe pulmonary hypertension. This article represents the current opinion of all consortium members in Europe for the optimal neonatal treatment of CDH.
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Affiliation(s)
- Kitty G Snoek
- Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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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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O'Shea JE, Thio M, Kamlin CO, McGrory L, Wong C, John J, Roberts C, Kuschel C, Davis PG. Videolaryngoscopy to Teach Neonatal Intubation: A Randomized Trial. Pediatrics 2015; 136:912-9. [PMID: 26482669 DOI: 10.1542/peds.2015-1028] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Neonatal endotracheal intubation is a necessary skill. However, success rates among junior doctors have fallen to <50%, largely owing to declining opportunities to intubate. Videolaryngoscopy allows instructor and trainee to share the view of the pharynx. We compared intubations guided by an instructor watching a videolaryngoscope screen with the traditional method where the instructor does not have this view. METHODS A randomized, controlled trial at a tertiary neonatal center recruited newborns from February 2013 to May 2014. Eligible intubations were performed orally on infants without facial or airway anomalies, in the delivery room or neonatal intensive care, by doctors with <6 months' tertiary neonatal experience. Intubations were randomized to having the videolaryngoscope screen visible to the instructor or covered (control). The primary outcome was first-attempt intubation success rate confirmed by colorimetric detection of expired carbon dioxide. RESULTS Two hundred six first-attempt intubations were analyzed. Median (interquartile range) infant gestation was 29 (27 to 32) weeks, and weight was 1142 (816 to 1750) g. The success rate when the instructor was able to view the videolaryngoscope screen was 66% (69/104) compared with 41% (42/102) when the screen was covered (P < .001, OR 2.81, 95% CI 1.54 to 5.17). When premedication was used, the success rate in the intervention group was 72% (56/78) compared with 44% (35/79) in the control group (P < .001, OR 3.2, 95% CI 1.6 to 6.6). CONCLUSIONS Intubation success rates of inexperienced neonatal trainees significantly improved when the instructor was able to share their view on a videolaryngoscope screen.
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Affiliation(s)
- Joyce E O'Shea
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; Department of Paediatrics, Royal Hospital for Children, Glasgow, Scotland; University College Cork, Cork, Ireland; University of Glasgow, Glasgow, Scotland; joyce.o'
| | - Marta Thio
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; PIPER-Neonatal Transport, The Royal Children's Hospital Melbourne, Australia
| | - C Omar Kamlin
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; and
| | - Lorraine McGrory
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; University of Dundee, Dundee, Scotland
| | - Connie Wong
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia
| | - Jubal John
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia
| | - Calum Roberts
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Carl Kuschel
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Peter G Davis
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; and
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Mussavi M, Asadollahi K, Abangah G, Saradar S, Abbasi N, Zanjani F, Aminizade M. Application of Lidocaine Spray for Tracheal Intubation in Neonates - A Clinical Trial Study. IRANIAN JOURNAL OF PEDIATRICS 2015. [PMID: 26199688 PMCID: PMC4505970 DOI: 10.5812/ijp.245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Tracheal intubation is extremely distressing, painful, and may influence heart rate and blood pressure. Sedatives, analgesics, and muscle relaxants are not commonly used for intubation in neonates. Objectives: This study aimed to evaluate the effects of lidocaine spray as a non-intravenous drug before neonatal intubation on blood pressure, heart rate, oxygen saturation and time of intubation. Patients and Methods: In a randomized, controlled study each neonate was randomly assigned to one of the two study groups by staffs who were not involved in the infant's care. The allocation concealment was kept in an opaque sealed envelope, and the investigators, the patient care team, and the assessors were blinded to the treatment allocation. The selected setting was NICU unit of a teaching hospital in Ilam city, Iran and participants were 60 neonates with indication of tracheal intubation with gestational age > 30 weeks. Patients in the treatment group received lidocaine spray and the placebo group received spray of normal saline prior to intubation. Main outcome measurements were the mean rates of blood pressure, heart rate, oxygen saturation, intubation time and lidocaine side effects were measured before and after intubation. Results: Totally 60 newborns including 31 boys and 29 girls were entered into the study (drug group n = 30; placebo group n = 30). Boy/girl ratio in treatment and placebo groups were 1.3 and 0.88, respectively. Mean age ± SD of participants was 34.1 ± 24.8 hours (treatment: 35.3 ± 25.7; placebo: 32.9 ± 24.3; P < 0.0001). Mean weight ± SD of neonates was 2012.5 ± 969 g. Application of lidocaine spray caused a significant reduction of mean intubation time among treatment group compared with placebo group (treatment: 15.03 ± 2.2 seconds; placebo: 18.3 ± 2.3 seconds; P < 0.0001). Mean blood pressure, heart rate and oxygen saturation rate, among neonates in treatment group was reduced after intubation compared with their relevant figures before intubation; however, their differences were not statistically significant except for mean oxygen saturation rate that was reduced significantly in placebo group. No side effects were observed during study. Conclusions: Though the current study revealed some promising results in the application of lidocaine spray during neonatal intubation without any considerable side effects; however, the current investigation could only be considered as a pilot study for further attempts in different locations with higher sample sizes and in different situations.
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Affiliation(s)
- Mirhadi Mussavi
- Department of Pediatrics,Pediatric research center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Khairollah Asadollahi
- Department of Epidemiology, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, IR Iran
- Research Centre for Psychosocial Injuries, Ilam University of Medical Sciences, Ilam, IR Iran
- Corresponding author: Khairollah Asadollahi, Department of Epidemiology, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, IR Iran. Tel: +98-8412227126, Fax: +98-8412227120, E-mail:
| | - Ghobad Abangah
- Department of Gastroenterology, Ilam University of Medical Sciences, Ilam, IR Iran
| | - Sirus Saradar
- Department of Pediatrics,Pediatric research center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Naser Abbasi
- Department of Pharmacology, Iran University of Medical Sciences, Tehran, IR Iran
| | - Fereidon Zanjani
- Department of Anaesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Mahsa Aminizade
- Department of Emergency Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, IR Iran
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Smith KA, Gothard MD, Schwartz HP, Giuliano JS, Forbes M, Bigham MT. Risk Factors for Failed Tracheal Intubation in Pediatric and Neonatal Critical Care Specialty Transport. PREHOSP EMERG CARE 2014; 19:17-22. [PMID: 25350689 DOI: 10.3109/10903127.2014.964888] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Objective. Nearly 200,000 pediatric and neonatal transports occur in the United States each year with some patients requiring tracheal intubation. First-pass intubation rates in both pediatric and adult transport literature are variable as are the factors that influence intubation success. This study sought to determine risk factors for failed tracheal intubation in neonatal and pediatric transport. Methods. A retrospective chart review was performed over a 2.5-year period. Data were collected from a hospital-based neonatal/pediatric critical care transport team that transports 2,500 patients annually, serving 12,000 square miles. Patients were eligible if they were transported and tracheally intubated by the critical care transport team. Patients were categorized into two groups for data analysis: (1) no failed intubation attempts and (2) at least one failed intubation attempt. Data were tabulated using Epi Info Version 3.5.1 and analyzed using SPSSv17.0. Results. A total of 167 patients were eligible for enrollment and were cohorted by age (48% pediatric versus 52% neonatal). Neonates were more likely to require multiple attempts at intubation when compared to the pediatric population (69.6% versus 30.4%, p = 0.001). Use of benzodiazepines and neuromuscular blockade was associated with increased successful first attempt intubation rates (p = 0.001 and 0.008, respectively). Use of opiate premedication was not associated with first-attempt intubation success. The presence of comorbid condition(s) was associated with at least one failed intubation attempt (p = 0.006). Factors identified with increasing odds of at least one intubation failure included, neonatal patients (OR 3.01), tracheal tube size ≤ 2.5 mm (OR 3.78), use of an uncuffed tracheal tube (OR 6.85), and the presence of a comorbid conditions (OR 2.64). Conclusions. There were higher rates of tracheal intubation failure in transported neonates when compared to pediatric patients. This risk may be related to the lack of benzodiazepine and neuromuscular blocking agents used to facilitate intubation. The presence of a comorbid condition is associated with a higher risk of tracheal intubation failure.
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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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Impact of premedication on neonatal intubations by pediatric and neonatal trainees. J Perinatol 2014; 34:458-60. [PMID: 24577435 DOI: 10.1038/jp.2014.32] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 01/18/2014] [Accepted: 01/24/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine if premedication and training level affect the success rates of neonatal intubations. STUDY DESIGN We retrospectively reviewed a hospital-approved neonatal intubation database from 2003 to 2010. Intubation success rate was defined as the number of successful intubations divided by the total number of attempts, and then compared by trainee's experience level and the use of premedication. Premedication regimen included anticholinergic, analgesic and muscle relaxant agents. RESULT There were 169 trainees who completed 1071 successful intubations with 2694 attempts. The median success rate was 36% by all trainees, and improved with training level from 29% for pediatric trainees to 50% for neonatal trainees (P<0.001). Premedication was used in 58% of intubation attempts. The median success rate was double with premedication (43% versus 22%, P<0.001). CONCLUSION Neonatal endotracheal intubation is a challenge for trainees. Intubation success rates progressively improve with experience. Premedication is associated with improved success rates for all training levels.
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Durrmeyer X, Dahan S, Delorme P, Blary S, Dassieu G, Caeymaex L, Carbajal R. Assessment of atropine-sufentanil-atracurium anaesthesia for endotracheal intubation: an observational study in very premature infants. BMC Pediatr 2014; 14:120. [PMID: 24886350 PMCID: PMC4028002 DOI: 10.1186/1471-2431-14-120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 04/25/2014] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Xavier Durrmeyer
- Epidemiology and Biostatistics Centre, Obstetrical, Perinatal and Pediatric Epidemiology Team, Université Pierre et Marie Curie Paris VI, Paris, Inserm UMRS 1153, France.
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Avino D, Zhang WH, De Villé A, Johansson AB. Remifentanil versus morphine-midazolam premedication on the quality of endotracheal intubation in neonates: a noninferiority randomized trial. J Pediatr 2014; 164:1032-7. [PMID: 24582007 DOI: 10.1016/j.jpeds.2014.01.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 12/02/2013] [Accepted: 01/15/2014] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To compare remifentanil and morphine-midazolam for use in nonurgent endotracheal intubation in neonates. STUDY DESIGN In this prospective noninferiority randomized trial, newborns of gestational age ≥28 weeks admitted in the neonatal intensive care unit requiring an elective or semielective endotracheal intubation were divided into 2 groups. One group (n = 36) received remifentanil (1 μg/kg), and the other group (n = 35) received morphine (100 μg/kg) and midazolam (50 μg/kg) at a predefined time before intubation (different in each group), to optimize the peak effect of each drug. Both groups also received atropine (20 μg/kg). The primary outcome was to compare the conditions of intubation, and the secondary outcome was to compare the duration of successful intubation, physiological variables, and pain scores between groups for first and second intubation attempts. Adverse events and neurologic test data were reported. RESULTS Intubation with remifentanil was not inferior to that with morphine-midazolam. At the first attempted intubation, intubation conditions were poor in 25% of the remifentanil group and in 28.6% of the morphine-midazolam group (P = .471). For the second attempt, conditions were poor in 28.6% of the remifentanil group, compared with 10% of the morphine-midazolam group (P = .360). The median time to successful intubation was 33 seconds (IQR, 24-45 seconds) for the remifentanil group versus 36 seconds (IQR, 25-59 seconds) for the morphine-medazolam group (P = .359) at the first attempt and 45 seconds (IQR, 35-64 seconds) versus 56 seconds (IQR, 44-68 seconds), respectively, for the second attempt (P = .302). No significant between-group difference was reported for hypotension, bradycardia, or adverse events. CONCLUSION In our cohort, remifentanil was at least as effective as the morphine-midazolam regimen for endotracheal intubation. Thus, premedication using this very-short-acting opioid can be considered in urgent intubations and is advantageous in rapid extubation.
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Affiliation(s)
- Daniela Avino
- Neonatal Intensive Care Unit, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium.
| | - Wei-Hong Zhang
- Epidemiology, Biostatistics and Clinical Research Center, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrée De Villé
- Department of Anesthesiology, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | - Anne-Britt Johansson
- Neonatal Intensive Care Unit, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
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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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Clinical pharmacology of midazolam in neonates and children: effect of disease-a review. Int J Pediatr 2014; 2014:309342. [PMID: 24696691 PMCID: PMC3948203 DOI: 10.1155/2014/309342] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 12/26/2013] [Indexed: 12/04/2022] Open
Abstract
Midazolam is a benzodiazepine with rapid onset of action and short duration of effect. In healthy neonates the half-life (t1/2) and the clearance (Cl) are 3.3-fold longer and 3.7-fold smaller, respectively, than in adults. The volume of distribution (Vd) is 1.1 L/kg both in neonates and adults. Midazolam is hydroxylated by CYP3A4 and CYP3A5; the activities of these enzymes surge in the liver in the first weeks of life and thus the metabolic rate of midazolam is lower in neonates than in adults. Midazolam acts as a sedative, as an antiepileptic, for those infants who are refractory to standard antiepileptic therapy, and as an anaesthetic. Information of midazolam as an anaesthetic in infants are very little. Midazolam is usually administered intravenously; when minimal sedation is required, intranasal administration of midazolam is employed. Disease affects the pharmacokinetics of midazolam in neonates; multiple organ failure reduces the Cl of midazolam and mechanical ventilation prolongs the t1/2 of this drug. ECMO therapy increases t1/2, Cl, and Vd of midazolam several times. The adverse effects of midazolam in neonates are scarce: pain, tenderness, and thrombophlebitis may occur. Respiratory depression and hypotension appear in a limited percentage of infants following intravenous infusion of midazolam. In conclusion, midazolam is a safe and effective drug which is employed as a sedative, as antiepileptic agent, for infants who are refractory to standard antiepileptic therapy, and as an anaesthetic.
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Sedation of newborn infants for the INSURE procedure, are we sure? BIOMED RESEARCH INTERNATIONAL 2013; 2013:892974. [PMID: 24455736 PMCID: PMC3885201 DOI: 10.1155/2013/892974] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 11/28/2013] [Indexed: 11/17/2022]
Abstract
Background. Neonatal intubation is a stressful procedure that requires premedication to improve intubation conditions and reduce stress and adverse physiological responses. Premedication used during the INSURE (INtubation, SURfactant therapy, Extubation) procedure should have a very short duration of action with restoration of spontaneous breathing within a few minutes. Aims. To determine the best sedative for intubation during the INSURE procedure by systematic review of the literature. Methods. We reviewed all relevant studies reporting on premedication, distress, and time to restoration of spontaneous breathing during the INSURE procedure. Results. This review included 12 studies: two relatively small studies explicitly evaluated the effect of premedication (propofol and remifentanil) during the INSURE procedure, both showing good intubation conditions and an average extubation time of about 20 minutes. Ten studies reporting on fentanyl or morphine provided insufficient information about these items. Conclusions. Too little is known in the literature to draw a solid conclusion on which premedication could be best used during the INSURE procedure. Both remifentanil and propofol are suitable candidates but dose-finding studies to detect effective nontoxic doses in newborns with different gestational ages are necessary.
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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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Use of analgesic and sedative drugs in VLBW infants in German NICUs from 2003-2010. Eur J Pediatr 2013; 172:1633-9. [PMID: 23877637 DOI: 10.1007/s00431-013-2095-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 07/04/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED Very low birth weight (VLBW) infants frequently receive analgesia and/or sedation for painful procedures and mechanical ventilation to avoid negative stress. Yet, concerns remain regarding potential adverse long-term effects of these drugs on VLBW infants' neurocognitive outcome. Recent studies have shown that less invasive surfactant application (LISA) and early nasal CPAP treatment reduce the need for mechanical ventilation and painful procedures. Therefore, these measures might also reduce the application of analgesic and/or sedative drugs in VLBW infants. To evaluate this hypothesis and to identify potential changes in analgesic treatment concepts in recent years, we retrospectively analyzed data on analgesia and sedation, respiratory support, and the method of surfactant application in VLBW infants enrolled in the German Neonatal Network (GNN) trial between 2003 and 2009 (period 1) and compared it with data from infants participating in GNN in 2010 (period 2). In both periods, about one third of all infants were treated with analgesic and/or sedative drugs using a wide variety of substances. The administration of novel drugs such as propofol, sufentanil, or intravenous paracetamol was higher in 2010 (6.7 vs. 12.2 %). Infants who were treated with CPAP only received significantly less analgesic/sedative medication than infants who were mechanically ventilated (12 vs. 65 %, p=<0.001). Similarly, infants treated with LISA received less analgesic or sedative drugs as compared to infants who received surfactant via endotracheal intubation (36 vs. 63 %, p=0.001). CONCLUSION Although both avoidances of mechanical ventilation and less invasive surfactant application are associated with reduced analgesic or sedative treatment, the percentage of VLBW infants who received analgesia and/or sedation remained unchanged in Germany in recent years.
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Simons SHP, van der Lee R, Reiss IKM, van Weissenbruch MM. Clinical evaluation of propofol as sedative for endotracheal intubation in neonates. Acta Paediatr 2013; 102:e487-92. [PMID: 23889264 DOI: 10.1111/apa.12367] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 07/16/2013] [Accepted: 07/22/2013] [Indexed: 11/30/2022]
Abstract
AIM To determine the effects of propofol for endotracheal intubation in neonates in daily clinical practice. METHODS We prospectively studied the pharmacodynamic effects of intravenous propofol administration in neonates who needed endotracheal intubation at the neonatal intensive care unit. RESULTS Propofol was used for 62 intubations in neonates with postmenstrual ages ranging from 24 + 3 weeks to 44 + 5 weeks and bodyweights ranging from 520 to 4380 g. A 2 mg/kg bodyweight propofol starting dose was sufficient in 37% of patients; additional propofol was needed less often on the first postnatal day. The mean amount of propofol used was 3.3 (±1.2) mg/kg. The success rate of intubation depended on the experience of the physician and was related to the total administered amount of propofol. Hypotension occurred in 39% of patients and occurred more often at the first postnatal day. In 15% of procedures, propofol mono therapy was insufficient. CONCLUSION This study shows that high doses of propofol are needed to reach effective sedation in neonates for intubation, with hypotension as a side effect in a considerable percentage of patients. Further research in newborn patients needs to identify optimal propofol doses and risk factors for hypotension.
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Affiliation(s)
- SHP Simons
- Division of Neonatology; Department of Pediatrics; Erasmus MC Sophia Children's Hospital; Rotterdam; The Netherlands
| | - R van der Lee
- Department of Neonatology; AMC Emma Children's Hospital; Amsterdam; The Netherlands
| | - Irwin KM Reiss
- Division of Neonatology; Department of Pediatrics; Erasmus MC Sophia Children's Hospital; Rotterdam; The Netherlands
| | - MM van Weissenbruch
- Department of Neonatology; VU Medical Center Amsterdam; Amsterdam; The Netherlands
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Lopez E, Gascoin G, Flamant C, Merhi M, Tourneux P, Baud O. Exogenous surfactant therapy in 2013: what is next? Who, when and how should we treat newborn infants in the future? BMC Pediatr 2013; 13:165. [PMID: 24112693 PMCID: PMC3851818 DOI: 10.1186/1471-2431-13-165] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 09/19/2013] [Indexed: 11/10/2022] Open
Abstract
Background Surfactant therapy is one of the few treatments that have dramatically changed clinical practice in neonatology. In addition to respiratory distress syndrome (RDS), surfactant deficiency is observed in many other clinical situations in term and preterm infants, raising several questions regarding the use of surfactant therapy. Objectives This review focuses on several points of interest, including some controversial or confusing topics being faced by clinicians together with emerging or innovative concepts and techniques, according to the state of the art and the published literature as of 2013. Surfactant therapy has primarily focused on RDS in the preterm newborn. However, whether this treatment would be of benefit to a more heterogeneous population of infants with lung diseases other than RDS needs to be determined. Early trials have highlighted the benefits of prophylactic surfactant administration to newborns judged to be at risk of developing RDS. In preterm newborns that have undergone prenatal lung maturation with steroids and early treatment with continuous positive airway pressure (CPAP), the criteria for surfactant administration, including the optimal time and the severity of RDS, are still under discussion. Tracheal intubation is no longer systematically done for surfactant administration to newborns. Alternative modes of surfactant administration, including minimally-invasive and aerosolized delivery, could thus allow this treatment to be used in cases of RDS in unstable preterm newborns, in whom the tracheal intubation procedure still poses an ethical and medical challenge. Conclusion The optimization of the uses and methods of surfactant administration will be one of the most important challenges in neonatal intensive care in the years to come.
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Affiliation(s)
- Emmanuel Lopez
- Réanimation et Pédiatrie Néonatales, Groupe Hospitalier Robert Debré, APHP, 48 Bd Sérurier, Paris, 75019, France.
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