Pre-medication for Intubation

Roberts KD, Leone TA, Edwards WH, et al. Pre-medication for Nonemergent Neonatal Intubations: A Randomized, Controlled Trial Comparing Atropine and Fentanyl to Atropine, Fentanyl, and Mivacurium. Pediatrics (October 2006); 118:1583-1591 . [Full Text.] [Reprint (PDF)]

OBJECTIVE. The purpose of this work was to investigate whetherusing a muscle relaxant would improve intubation conditionsin infants, thereby decreasing the incidence and duration ofhypoxia and time and number of attempts needed to successfullycomplete the intubation procedure.
PATIENTS/METHODS. This was a prospective, randomized, controlled,2-center trial. Infants requiring nonemergent intubation were randomly assigned to receive atropine and fentanyl or atropine, fentanyl, and mivacurium before intubation. Incidence and durationof hypoxia were determined at oxygen saturation thresholds of

85%,

75%,

60%, and

40%. Videotape was reviewed to determinethe time and number of intubation attempts and duration of actionof mivacurium.
RESULTS. Analysis of 41 infants showed that incidence of oxygensaturation

60% of any duration was significantly less in themivacurium group (55% vs. 24%). The incidence of saturation levelof any duration

85%, 75%, and 40%; cumulative time

30 seconds;and time below the thresholds were not significantly different.Total procedure time (472 vs. 144 seconds) and total laryngoscopetime (148 vs. 61 seconds) were shorter in the mivacurium group.Successful intubation was achieved in

2 attempts significantlymore often in the mivacurium group (35% vs. 71%).
CONCLUSIONS. Pre-medication with atropine, fentanyl, and mivacuriumcompared with atropine and fentanyl without a muscle relaxantdecreases the time and number of attempts needed to successfullyintubate while significantly reducing the incidence of severedesaturation. Pre-medication including a short-acting musclerelaxant should be considered for all non-emergent intubations in the NICU.

Comments. I guess those of us who are still doing elective neonatal intubations without pre-medication are really “old school”. Intubation without pre-medication is associated with an increased incidence of hypoxia, bradycardia, blood pressure fluctuations and increases in intracranial pressure. Atropine (0.02 mg/kg over 1 min) attenuates the bradycardic response, while fentanyl (2 mcg/kg over 5 min) attenuates the hypertension, and muscle relaxants (mivacurium 0.2 mg/kg IV push) blunt the increase in ICP. This sounds like a more humane practice, and I plan to give it a try. ABK

Using the three medications in elective intubations is definitely a more "humane" practice. I wonder why the Neonatal Resuscitation Program has not incorporated this in the latest NRP Update??

UserName: Ravi Agarwal, MD
Institution:
telephone: 908-531-1705
email: neodoc1@yahoo.com

Chest wall rigidity is currently described with fentanyl or sufentanyl (at least 45 recent papers on Medline) so that we don't use synthetic opioids anymore but morphine itself which does not induce this severe complication. The use of an associated hypnotic drug such as midazolam permits to avoid curarisation as the baby does not move during the procedure. Atropine is clearly beneficial. We would like to underline the fact that this is general anesthesia, not pre-medication; this intervention needs to be done by well trained physicians with precise protocols.

UserName: Betremieux
Institution: RENNES Teaching Hospital france
telephone: +33 2 99 28 43 12
email: pierre.betremieux@chu-rennes.fr

Inspite of using three drugs why not to give diazapam as premedication for intubatins. We have used it many times with dosage 0.1-0.3mg iv without any side effects and quick in action.

UserName: Dr. Javed Habibullah
Institution: Al Wasl Hospital Dubai UAE
telephone: 00971504554899
email: jhabibullah@dohms.gov.ae

Over the last years we used a few regimens of premedication in a non-emergency-setting. We have seen thorax-rigidity with fentanly and we stopped using midzolam because of appearing seizures. Since using a atropine, opioids and relaxation we have had less to no problems.

UserName: Bernhard Bungert
Institution: Childrens hospital NICU Hanau, Germany
telephone: 004961812965000
email: bernhard_bungert@web.de

I must add that the association of Thiopental 5 mg/kg and Atropine 20 microgrammes/kg provide a general anesthesia during 5 minutes without Chest wall rigidity with a very good comfort for both patient and physician. Control of hypotension is mandatory but we note no change on stable babies.

UserName: Bétrémieux
Institution: NICU Rennes University France
telephone: + 33 99 28 43 12
email: pierre.betremieux@chu-rennes.fr

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