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Arribas C, Cavallaro G, Gonzalez JL, Lagares C, Raffaeli G, Smits A, Simons SHP, Villamor E, Allegaert K, Garrido F. Global cross-sectional survey on neonatal pharmacologic sedation and analgesia practices and pain assessment tools: impact of the sociodemographic index (SDI). Pediatr Res 2024:10.1038/s41390-024-03032-7. [PMID: 38351093 DOI: 10.1038/s41390-024-03032-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND There is variability in the use of sedatives and analgesics in neonatal intensive care units (NICUs). We aimed to investigate the use of analgesics and sedatives and the management of neonatal pain and distress. METHODS This was a global, prospective, cross-sectional study. A survey was distributed May-November 2022. The primary outcome of this research was to compare results between countries depending on their socio-sanitary level using the sociodemographic index (SDI). We organized results based on geographical location. RESULTS The survey collected 1304 responses, but we analyzed 924 responses after database cleaning. Responses from 98 different countries were analyzed. More than 60% of NICUs reported having an analgosedation guideline, and one-third of respondents used neonatal pain scales in more than 80% of neonates. We found differences in the management of sedation and analgesia between NICUs on different continents, but especially between countries with different SDIs. Countries with a higher SDI had greater availability of and adherence to analgosedation guidelines, as well as higher rates of analgosedation for painful or distressing procedures. Countries with different SDIs reported differences in analgosedation for neonatal intubation, invasive ventilation, and therapeutic hypothermia, among others. CONCLUSIONS Socio-economic status of countries impacts on neonatal analgosedation management. IMPACT There is significant variability in the pain management practices in neonates. There is a lack of knowledge related to how neonatal pain management practices differ between regions. Sociodemographic index is a key factor associated with differences in neonatal pain management practices across global regions.
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Affiliation(s)
- Cristina Arribas
- Department of Pediatrics, Neonatal Intensive Care Unit, Clínica Universidad de Navarra, Calle Marquesado de Santa Marta, 1, Madrid, 28027, Spain
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122, Milan, Italy.
| | - Juan-Luis Gonzalez
- Department of Statistics and Operations Research, Faculty of Medicine, University of Cadiz, 11003, Cádiz, Spain
| | - Carolina Lagares
- Department of Statistics and Operations Research, Faculty of Medicine, University of Cadiz, 11003, Cádiz, Spain
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122, Milan, Italy
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Eduardo Villamor
- MosaKids Children's Hospital, Maastricht University Medical Center (MUMC + ), School for Oncology and Reproduction (GROW), Maastricht University, 6202AZ, Maastricht, The Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, The Netherlands
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Felipe Garrido
- Department of Pediatrics, Neonatal Intensive Care Unit, Clínica Universidad de Navarra, Calle Marquesado de Santa Marta, 1, Madrid, 28027, Spain
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de Kort EH, Prins SA, Reiss IK, Willemsen SP, Andriessen P, van Weissenbruch MM, Simons SH. Propofol for endotracheal intubation in neonates: a dose-finding trial. Arch Dis Child Fetal Neonatal Ed 2020; 105:489-495. [PMID: 31932363 PMCID: PMC7547906 DOI: 10.1136/archdischild-2019-318474] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/21/2019] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To find propofol doses providing effective sedation without side effects in neonates of different gestational ages (GA) and postnatal ages (PNA). DESIGN AND SETTING Prospective multicentere dose-finding study in 3 neonatal intensive care units. PATIENTS Neonates with a PNA <28 days requiring non-emergency endotracheal intubation. INTERVENTIONS Neonates were stratified into 8 groups based on GA and PNA. The first 5 neonates in every group received a dose of 1.0 mg/kg propofol. Based on sedative effect and side effects, the dose was increased or decreased in the next 5 patients until the optimal dose was found. MAIN OUTCOME MEASURES The primary outcome was the optimal single propofol starting dose that provides effective sedation without side effects in each age group. RESULTS After inclusion of 91 patients, the study was prematurely terminated because the primary outcome was only reached in 13% of patients. Dose-finding was completed in 2 groups, but no optimal propofol dose was found. Effective sedation without side effects was achieved more often after a starting dose of 2.0 mg/kg (28%) than after 1.0 mg/kg (3%) and 1.5 mg/kg (9%). Propofol-induced hypotension occurred in 59% of patients. Logistic regression analyses showed that GA and PNA did not predict effective sedation or the occurrence of hypotension. CONCLUSIONS Effective sedation without side effects is difficult to achieve with propofol and the optimal dose in different age groups of neonates could not be determined. The sedative effect of propofol and the occurrence of hypotension are unpredictable and show large inter-individual variability in the neonatal population.
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Affiliation(s)
- Ellen H.M. de Kort
- Neonatology, Maxima Medical Center, Veldhoven, The Netherlands,Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sandra A. Prins
- Neonatology, Amsterdam UMC location VU Medical Center, Amsterdam, The Netherlands
| | - Irwin K.M. Reiss
- Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | | | | | - Sinno H.P. Simons
- Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Mari J, Franczia P, Margas W, Rutkowski J, Bebrysz M, Bokiniec R, Seliga‐Siwecka J. International consensus is needed on premedication for non-emergency neonatal intubation after survey found wide-ranging policies and practices in 70 countries. Acta Paediatr 2020; 109:1369-1375. [PMID: 31797442 DOI: 10.1111/apa.15119] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/01/2019] [Accepted: 12/02/2019] [Indexed: 12/25/2022]
Abstract
AIM This study evaluated whether practitioners from 70 countries used premedication for non-emergency neonatal intubation and identified attitudes and experience regarding the safety, side effects and efficiency of neonatal intubation. METHODS Invitations to take part in the survey were issued between December 18, 2018 and February 4, 2019 to the users of neonatal-based websites and Facebook groups, members of professional societies and the authors of relevant publications in the last five years. RESULTS We analysed 718 completed questionnaires from 40 European and 30 non-European countries. Most of the responses were from neonatologists (69.6%) and paediatric or neonatal trainees (10.3%). In units without a protocol (31.6%), more than half of the practitioners (60.4%) chose premedication according to personal preference and 37.0%-11.9% of the overall respondents did not use any drugs for non-emergency intubation. The most frequently reported drug combination was fentanyl, atropine and succinylcholine (6.8%). Most of the practitioners (78.5%) use the same drugs for term and preterm infants. Only 24.8% of the physicians were fully satisfied with their premedication practices. CONCLUSION Nearly 12% of the respondents did not use premedication for non-emergency neonatal intubation. The wide-ranging policies and practices found among the respondents highlight the need for international consensus guidelines.
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Affiliation(s)
- Judit Mari
- Paediatric Department University of Szeged Szeged Hungary
| | | | | | | | | | - Renata Bokiniec
- Department of Neonatology and Neonatal intensive Care Medical University of Warsaw Warsaw Poland
| | - Joanna Seliga‐Siwecka
- Department of Neonatology and Neonatal intensive Care Medical University of Warsaw Warsaw Poland
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Abstract
Non-invasive ventilation is currently the preferred respiratory support for premature infants with respiratory distress. The lung-protective effects of non-invasive ventilation should however not prompt disregard for the possible pain and discomfort it can generate. Non-pharmacological interventions should be used in all premature infants, regardless of their respiratory support, and are not detailed in this review. This review includes currently available evidence and gaps in knowledge regarding three aspects of pain management in premature infants receiving non-invasive ventilation: optimisation of non-invasive ventilation especially through the choice of positive pressure source, appropriate interface and synchronisation; sedative or analgesic drug use for strategies aiming at administering surfactant with reduction or avoidance of tracheal ventilation; risks and benefits of some analgesic and/or sedative drugs used to treat or prevent prolonged pain and discomfort during non-invasive ventilation. In spite of limited robust evidence, this overview should trigger caregivers' reflections on their daily practice.
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Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events. J Perinatol 2019; 39:848-856. [PMID: 30940929 DOI: 10.1038/s41372-019-0367-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/20/2019] [Accepted: 02/25/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To determine the impact of premedication for tracheal intubation (TI) on adverse TI associated events, severe oxygen desaturations, and first attempt success STUDY DESIGN: Retrospective cohort study in neonatal intensive care units (NICU) participating in the National Emergency Airway Registry for Neonates from 10/2014 to 6/2017. Premedication for TI was categorized as sedation with neuromuscular blockade, sedation only, or no medication. RESULTS 2260 TIs were reported from 11 NICUs. Adverse TI associated events occurred less often in sedation with neuromuscular blockade group (10%) as compared to sedation only (29%), or no medication group (23%), p < 0.001. The adjusted odds ratio (aOR) for adverse TI associated events were: sedation with neuromuscular blockade aOR 0.48 (95%CI 0.34-0.65, p < 0.001) compared to no medication. CONCLUSION Use of sedation with neuromuscular blockade was associated with favorable TI outcomes. This study supports the recommendation for the standard use of sedation with neuromuscular blockade in non-emergency TIs.
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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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Milési C, Baleine J, Mura T, Benito-Castro F, Ferragu F, Thiriez G, Thévenot P, Combes C, Carbajal R, Cambonie G. Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial. Arch Dis Child Fetal Neonatal Ed 2018; 103:F221-F226. [PMID: 28818854 DOI: 10.1136/archdischild-2017-312808] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/23/2017] [Accepted: 06/27/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the effectiveness of sedation by intranasal administration of midazolam (nMDZ) or ketamine (nKTM) for neonatal intubation. DESIGN A multicentre, prospective, randomised, double-blind study. SETTING Delivery rooms at four tertiary perinatal centres in France. PATIENTS Preterm neonates with respiratory distress requiring non-emergent endotracheal intubation for surfactant instillation. INTERVENTIONS Treatment was randomly allocated, with each neonate receiving a bolus of 0.1 mL/kg in each nostril, corresponding to 0.2 mg/kg for nMDZ and 2 mg/kg for nKTM. The drug was repeated once 7 min later at the same dose if adequate sedation was not obtained. MAIN OUTCOME MEASURES Success was defined by adequate sedation before intubation and adequate comfort during the procedure. Intubation features, respiratory and cardiovascular events were recorded. RESULTS Sixty newborns, with mean (SD) gestational age and birth weight of 28 (3) weeks and 1100 (350) g, were included within the first 20 min of life. nMDZ was associated with a higher success rate (89% vs 58%; RR: 1.54, 95% CI 1.12 to 2.12, p<0.01) and shorter delays between the first dose and intubation (10 (6) vs 16 (8) min, p<0.01).Number of attempts, time to intubation, mean arterial blood pressure measures over the first 12 hours after birth and length of invasive ventilation were not different. CONCLUSIONS nMDZ was more efficient than nKTM to adequately sedate neonates requiring intubation in the delivery room. The haemodynamic and respiratory effects of both drugs were comparable. CLINICAL TRIAL This clinical trial was recorded on the National Library of Medicine registry (NCT01517828).
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Affiliation(s)
- Christophe Milési
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University, Montpellier, France
| | - Julien Baleine
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University, Montpellier, France
| | - Thibault Mura
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier University Hospital, Montpellier, France
| | - Fernando Benito-Castro
- Department of Neonatal Medicine, Carémeau Hospital, Nîmes University Hospital, Nimes, France
| | - Félicie Ferragu
- Department of Neonatal Medicine, Carémeau Hospital, Nîmes University Hospital, Nimes, France
| | - Gérard Thiriez
- Department of Neonatal Medicine, Jean Minjoz Hospital, Besançon University Hospital, Besancon, France
| | - Pierre Thévenot
- Department of Neonatal Medicine, St Jean Hospital, Perpignan General Hospital, Perpignan, France
| | - Clémentine Combes
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University, Montpellier, France
| | - Ricardo Carbajal
- Paediatric Emergency Unit, Armand Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Pierre and Marie Curie University, Paris, France
| | - Gilles Cambonie
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University, Montpellier, France
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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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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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Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study. Pediatr Crit Care Med 2015; 16:210-8. [PMID: 25581629 DOI: 10.1097/pcc.0000000000000319] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Tracheal intubation in PICUs is often associated with adverse tracheal intubation-associated events. There is a paucity of data regarding medication selection for safe tracheal intubations in PICUs. Our primary objective was to evaluate the association of medication selection on specific tracheal intubation-associated events across PICUs. DESIGN Prospective observational cohort study. SETTING Nineteen PICUs in North America. SUBJECTS Critically ill children requiring tracheal intubation. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Using the National Emergency Airway Registry for Children, tracheal intubation quality improvement data were prospectively collected from July 2010 to March 2013. Patient, provider, and practice characteristics including medications and dosages were collected. Adverse tracheal intubation-associated events were defined a priori. A total of 3,366 primary tracheal intubations were reported. Adverse tracheal intubation-associated events occurred in 593 tracheal intubations (18%). Fentanyl and midazolam were the most commonly used induction medications (64% and 58%, respectively). Neuromuscular blockade was used in 92% of tracheal intubation with the majority using rocuronium (64%) followed by vecuronium (20%). Etomidate and succinylcholine were rarely used (1.6% and 0.7%, respectively). Vagolytics were administered in 37% of tracheal intubations (51% in infants; 28% in > 1 yr old; p < 0.001). Ketamine was used in 27% of tracheal intubations but more often for tracheal intubations in patients with unstable hemodynamics (39% vs 25%; p < 0.001). However, ketamine use was not associated with lower prevalence of new hypotension (ketamine 8% vs no ketamine 14%; p = 0.08). CONCLUSIONS In this large, pediatric multicenter registry, fentanyl, midazolam, and ketamine were the most commonly used induction agents, and the majority of tracheal intubations involved neuromuscular blockade. Ketamine use was not associated with lower prevalence of hypotension.
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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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Foglia EE, Ades A, Napolitano N, Leffelman J, Nadkarni V, Nishisaki A. Factors Associated with Adverse Events during Tracheal Intubation in the NICU. Neonatology 2015; 108:23-9. [PMID: 25967680 PMCID: PMC4475443 DOI: 10.1159/000381252] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 02/25/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The incidence of adverse tracheal intubation-associated events (TIAEs) and associated patient, practice, and intubator characteristics in the neonatal intensive care unit (NICU) setting are unknown. OBJECTIVES To determine the incidence of adverse TIAEs and to identify factors associated with TIAEs in the NICU. METHODS Single-site prospective observational cohort study of infants who were intubated in a level 4 referral NICU between September 1, 2011 and November 30, 2013. A standardized pediatric airway registry was implemented to document patient, practice, and intubator characteristics and outcomes of intubation encounters. The primary outcome was adverse TIAEs. RESULTS Adverse TIAEs occurred in 153 of 701 (22%) tracheal intubation encounters. Factors that were independently associated with lower incidence of TIAEs in logistic regression included attending physician (vs. resident; odds ratio (OR) 0.4, 95% CI: 0.16, 0.98) and use of paralytic medication (OR 0.45, 95% CI: 0.25, 0.81). Severe oxygen desaturations (≥ 20% decrease in oxygen saturation) occurred in 51.1% of encounters and were more common in tracheal intubations performed by residents (62.8%), compared to fellows (43.2%) or attendings (47.5%; p = 0.008). CONCLUSIONS Adverse TIAEs and severe oxygen desaturation events are common in the NICU setting. Modifiable risk factors associated with TIAEs identified include intubator training level and use of paralytic medications.
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Affiliation(s)
- Elizabeth E Foglia
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pa., USA
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