Premedication for endotracheal intubation in the newborn infant

Question 1

What are the physiologic responss to intubation?

Answer 1

1. Systemic and pulmonary hypertension
2. Bradycardia (vagal)
3. Intracranial hypertension (from struggling)
4. Hypoxia

Question 2

What are the effects of premedication on the physiological responses?

Answer 2

1. Atropine prevents bradycardia
2. Adequate analgesia reduces systemic hypertension
3. Muscle relaxants prevents intracranial hypertension
4. RSI faster and thus reduced hypoxia

Question 3

How can the pain and discomfort of intubation be reduced?

Answer 3

1. Opiates
2. Barbiturates limited data
3. Propofol requires further investigation of single-dose use before recommending widespread use
4. Midazolam should not be used for intubation purposes in the newborn as causes hypotension, decreased CO, and decreased cerebral blood flow velocity and poor neurological outcomes

Question 4

What are the complications of premedicating an infant for intubation?

Answer 4

No increased rate of complication noted

Question 5

Under what clinical circumstances is it acceptable to intubate an infant without the use of premedication?

Answer 5

1. Infants who are being resuscitated and have poor ventilation and HR
2. Infants with extremely difficult vascular access
3. Infants with severely abnormal airways

Question 6

What are the characteristics of an acceptable protocol for premedication?

Answer 6

1. Vagolytic
2. Analgesia
3. Muscle relaxant

Question 7

What are other recommendations regarding ETT?

Answer 7

1. Preoxygenation
2. Limit duration of attempts to max 30s
3. Careful observation and monitoring during the procedure with pulse oximetry
4. Confirmation of appropriate ETT placement with CO2 detection

Question 8

What are the recommendations for intubation of neonates?

Answer 8

1. Intubations should be performed (or supervised) by trained staff with knowledge about the effects of the intubation process and the medications used.
2. During intubation, the infant should be monitored closely – pulse oximetry is usually the minimum monitoring required.
3. All newborn infants should receive analgesic premedication for endotracheal intubation, except for emergency intubations during resuscitation or infants in whom instrumentation of the airway is likely to be extremely difficult.
4. Vagolytic agents should be strongly considered; atropine at a dose of 20 µg/kg (there is no absolute minimum dose) is effective and safe if given once. 10 µg/kg may be sufficient.
5. Rapid-acting analgesic agents should be given; the current best choice is fentanyl.
6. Infants should receive fentanyl by slow IV infusion (1 min appears to be adequate) and muscle relaxants should be available when fentanyl is given to a nonintubated infant. Alternatively, routine use of a muscle relaxant following fentanyl administration could be considered.
7. Rapid-onset muscle relaxants should be considered. Agents of short duration will usually be preferable; succinylcholine in a dose of 2 mg/kg is currently considered to be the best choice.
8. A suggested protocol is:
   a) Atropine 20ug/kg IV
   b) Fentanyl 3-5ug/kg IV slow infusion
   c) Succinylcholine 2mg/kg IV
9. Further research is needed to determine the most appropriate medications and sequence. Newer very rapid-acting agents with short durations of action should be further investigated. Long-term outcomes should be assessed.

Question 9

What are some adverse effects of succinylcholine?

Answer 9

Depolarizing agent, rare serious complications, malignant hyperthermia, hyperkalaemia, rhabdomyolysis