Pain control for intubation by trainees

Because of my research interest in premedication for endotracheal intubation I have been asked several times to talk to groups about the subject, I have often been asked whether intubations by trainees should be premedicated, because their risk of failed intubations is greater. My response has been: premedication decreases the risk of failure, makes the procedure less painful for the baby, and increases the ease and speed of intubation, and those facts are true in studies where residents, and other trainees, have been part of the intubation teams, as well as when the teams were just senior people.

Data published recently from San Diego confirms these thoughts.

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.

I think this graph says it all

Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Success rates are very poor for interns and residents, and somewhat better for fellows. For every level of trainee, premedication improves success.  The success rates were calculated as successful intubation per attempt, and a trainee was allowed a maximum of 3 attempts before passing to the next most experienced person. So if you try twice for an individual baby, and get it on the second attempt then you have a 50% success rate.

I calculated from the data presented the success rate for intubations without paralysis, there weren’t many, as their routine cocktail includes a muscle relaxant. There were 186 premedicated intubations without muscle relaxant, with 54 successes. That gives a 29% success rate, which is intermediate between the non-medicated, and the fully premedicated intubations. All of which I think gives a lot of support to the AAP recommendation (and the CPS statement) that all non-emergency intubations should be premedicated, and a muscle relaxant included, unless there is a contra-indication. Whether or not trainees are doing the procedure.

The low success rates also say to me that the most fragile patients are no place to practice. With such low success rates, our trainees should start with formal training, then simulations with high-fidelity mannekins, then larger more stable babies under heavy supervision by a real expert (not a first year fellow who is just starting) perhaps with a video laryngoscope in recording mode to give feedback, and only when they have demonstrated competence then proceed to more immature, fragile at-risk babies.

About keithbarrington

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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