Evaluation of an Intubation Readiness Score to Assess Neonatal Sedation before Intubation

Abstract

Background: Premedication for neonatal intubation facilitates the procedure and reduces stress and physiological disturbances. However, no validated scoring system to assess the effect of premedication prior to intubation is available. Objective: To evaluate the usefulness of an Intubation Readiness Score (IRS) to assess the effect of premedication prior to intubation in newborn infants. Methods: Two-center prospective study in neonates who needed endotracheal intubation. Intubation was performed using a standardized procedure with propofol 1–2 mg/kg as premedication. The level of sedation was assessed with the IRS by evaluating the motor response to a firm stimulus (1 = spontaneous movement; 2 = movement on slight touch; 3 = movement on firm stimulus; 4 = no movement). Intubation was proceeded if an adequate effect, defined as an IRS of 3 or 4, was reached. IRS was compared to the quality of intubation measured with the Viby-Mogensen intubation score. Results: A total of 115 patients, with a median gestational age of 27.7 weeks (interquartile range 5.3) and a median birth weight of 1,005 g (interquartile range 940), were included. An adequate IRS was achieved in 105 patients, 89 (85%) of whom also had a good Viby-Mogensen intubation score and 16 (15%) had an inadequate Viby-Mogensen intubation score. The positive predictive value of the IRS was 85%. Conclusions: Preintubation sedation assessment using the IRS can adequately predict optimal conditions during intubation in the majority of neonates. We suggest using the IRS in routine clinical care. Further research combining the IRS with other parameters could further improve the predictability of adequate sedation during intubation.

Propofol for endotracheal intubation in neonates: a dose-finding trial

“…Propofol was used as standard of care for endotracheal intubation in our units. Propofol (Fresenius Kabi, Schelle, Belgium) was administered as intravenous bolus followed by a saline flush for a total duration of 30 s. After propofol administration, the pre-intubation sedation level was assessed every 30 s up to 3 min after the infusion, using the Intubation Readiness Score (IRS) 22. When the pre-intubation sedation level was adequate, intubation was continued.…”

“…Effective sedation was determined with two variables that both needed to be adequate: pre-intubation sedation level and quality of intubation. Pre-intubation sedation level was determined with the IRS, and adequate pre-intubation sedation level was defined as IRS 3 or 4 22. Quality of intubation was measured by the Viby-Mogensen intubation score 23.…”

“…Propofol (Fresenius Kabi, Schelle, Belgium) was administered as intravenous bolus followed by a saline flush for a total duration of 30 s. After propofol administration, the pre-intubation sedation level was assessed every 30 s up to 3 min after the infusion, using the Intubation Readiness Score (IRS). 22 When the pre-intubation sedation level was adequate, intubation was continued. In the case of insufficient pre-intubation sedation level after 3 min, additional propofol was administered until the pre-intubation sedation level was sufficient.…”

Propofol versus placebo (with rescue with ketamine) before less invasive surfactant administration: study protocol for a multicenter, double-blind, placebo controlled trial (PROLISA)

“…Within 2 min of injection of the first dose, a FANS pain score is rapidly evaluated after firmly rubbing the neonate's heel; according to a previously published intubation readiness score [33] (Fig. 1): The FANS scale (/10) allows a painful procedure to be evaluated, whether the face is visible or not.…”

“…-After the procedure: the clinician who successfully performed the LISA rates his/her performance during the laryngoscopy (especially the facility of exposure of the glottis) according to the Viby-Mogensen scale [33,36]. This score based on 5 items (scored from 0 to 4), explores the facility to expose the larynx and the infant's behavior [36].…”