What to give before intubation

The blog has been quiet recently, for various personal and professional reasons, but I will be getting back into the groove. I got really concerned over the last couple of days, my usually reliable personal PubNeoMed in my brain told me there was an article but whenever I tried to find it I came up with a zero. I kept saying to myself, I’m sure I’ve seen that article, and I’m sure it was by Neil Finer, Wade Rich and Tina Leone; I finally realized that I was searching using ‘newborn’ and not ‘neonatal’! One day computers will understand us better, until then I still have a role!

Le CN, Garey DM, Leone TA, Goodmar JK, Rich W, Finer NN: Impact of premedication on neonatal intubations by pediatric and neonatal trainees. J Perinatol 2014.

When I give presentations about premedication for endotracheal intubation, I sometimes get the comment that ‘we don’t use premedication because; what if the resident fails?’ I don’t understand the thinking behind such statements,  I wonder what the speaker would think if they were admitted to a teaching hospital with respiratory failure themselves, would they be happy having an awake intubation just in case the junior resident was unable to get the tube in the right hole? In any case this publication from San Diego shows that the success rate doubles when premedication is used, during intubations by trainees. So even if you are trying to teach this important skill to neonatal trainees, they have a much higher success rate, and more importantly the baby experiences much less pain and discomfort, if they get premedication than if they don’t.

But what to use? (Avino, D., et al. (2014). “Remifentanil versus Morphine-Midazolam Premedication on the Quality of Endotracheal Intubation in Neonates: A Noninferiority Randomized Trial.” J Pediatr).

This randomized trial compared remifentail, a very short duration opiate, to a morphine and midazolam combination. All infants in both groups received atropine, followed by either of the 2 opiate regimes. All the babies were intubated by neonatologists.

Overall there was very little differences between groups, most of the minor differences favoured remifentanil.

In this study, unlike some others, morphine was given 10 minutes before the intubation, which is reasonable as morphine takes at least this long to have a good effect.

On the other hand I have no idea why you would give midazolam for an intubation, I don’t think it has been recommended by any professional body, quite the opposite, as a sedative without analgesic properties, and an extremely variable, and often very prolonged duration of action, I think midazolam is a good example of a drug to avoid for intubation.

Also why did none of the infants, in either group, receive a muscle relaxant? This is never mentioned by the authors in their methods or their discussion, but muscle relaxation is routinely used in older patients, and has been shown to improve intubation conditions and shorten time to intubation in a number of studies in newborn infants.

Having said that this study does show, I think for the third time, that remifentainl can be used for intubation. Is it better for intubation conditions, and for weaning and extubating quickly, than other regimes? Not yet sure, but looks promising.

About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
This entry was posted in Neonatal Research and tagged , . Bookmark the permalink.

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