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PEDIATRICS

Efficacy of a Premedication Algorithm for Nonemergent Intubation in a Neonatal Intensive Care Unit

at time of study, Fellow, Neonatal–Perinatal Medicine, University of Michigan, Ann Arbor, MI; now, Staff Neonatologist, St. Luke's Regional Medical Center, Boise, ID

Robert E Schumacher, MD

Associate Professor, Pediatrics and Communicable Diseases, Department of Pediatrics, University of Michigan, Ann Arbor

Varsha Bhatt-Mehta, MS PharmD FCCP

Clinical Associate Professor, Pharmacy, Pediatrics, Communicable Diseases, Department of Pediatrics, College of Pharmacy, University of Michigan

Reprints: Dr. Bhatt-Mehta, Neonatal–Perinatal Medicine, University of Michigan Health System, F5790 CS Mott Children's Hospital, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, fax 734/763-7728, varsham{at}umich.edu

BACKGROUND: Preventing significant oxygen desaturation and hypotension through adequate analgesia and sedation during nonemergent intubation in neonates is desirable. However, in many neonatal intensive care units, elective intubations occur without adequate premedication. There is significant variation in the choice of premedication agent(s) and doses, and an ideal regimen for use during nonemergent intubation has not been developed.

OBJECTIVE: To evaluate the efficacy of an algorithm developed for analgesia and sedation during nonemergent intubation in neonates.

METHODS: Prospectively collected continuous quality improvement data on a premedication algorithm for nonemergent intubation were analyzed following institutional review board approval. Midazolam 0.1 mg/kg and fentanyl 2 µg/kg (if the patient was not already receiving morphine for sedation) were administered prior to nonemergent intubation. Heart rate, oxygen saturation, respiration rate, mean arterial pressure, and pain scores were recorded at baseline prior to medication administration, during the procedure, and for 2 hours after the procedure. Data during laryngoscopy and until the time of tube taping were obtained from the bedside cardiorespiratory monitor. Additional fentanyl was allowed for more than 3 intubation attempts and rocuronium 0.6 mg/kg was allowed for more than 5 attempts. The physiological changes that occurred over time were compared with baseline. The number of attempts made, time to intubation, and medications used are presented.

RESULTS: Ninety evaluable patients were included. Mean ± SD birth weight and postnatal age at treatment were 2040 ± 961 g and 14 ± 17 days, respectively. Heart rate decreased and oxygen saturation increased significantly (160 vs 154 beats/min, p = 0.01; 96.4% vs 93.8%, p = 0.002, respectively) from baseline to completion of the procedure; however, mean arterial pressure showed no significant difference (44.9 vs 44.7 mm Hg; p = 0.85; n = 68). The number of attempts at intubation were recorded for 66 patients; of those, 52 required 3 or fewer attempts for successful intubation (median, 2). The time to successful intubation was 7.2 ± 5.6 minutes (recorded in 45 pts.). Average fentanyl and midazolam doses were 1.92 ± 0.53 µg/kg and 0.096 ± 0.026 mg/kg, respectively. No patient received rocuronium.

CONCLUSIONS: A systematic approach to premedication during nonemergent intubation successfully prevented acute physiological changes.

Key Words: algorithm, neonatal intensive care, nonemergent intubation, premedication

Published Online, July 1, 2008. www.theannals.com, DOI 10.1345/aph.1K665