Insufficient Sedation and Severe Side Effects after Fast Administration of Remifentanil during INSURE in Preterm Newborns

Abstract

Background: Neonatal intubation is stressful and should be performed with premedication. In the case of an INSURE (intubation/surfactant/extubation) procedure a short duration of action of the premedication used is needed to facilitate fast extubation. Given its pharmacological profile, remifentanil seems a suitable candidate. Objectives: The aim here was to evaluate the effect and side effects of remifentanil as a premedication for preterm neonates undergoing INSURE. Methods: A prospective, single-center study in a level III neonatal intensive care unit was conducted. The quality of sedation was assessed in preterm infants receiving remifentanil prior to intubation for the INSURE procedure. Intravenous remifentanil was administered quickly and followed by a saline flush in approximately 30 s. The quality of sedation was defined by a combination of adequate sedation score, good intubation conditions and absence of side effects. Results: The study was terminated after the inclusion of 14 patients because of the high rate of side effects and the poor intubation conditions. Adequate sedation was achieved in only 2 patients (14%). Six patients (43%) needed additional propofol to obtain adequate sedation. Chest wall rigidity occurred in 6 patients (43%). Conclusions: The rapid administration of remifentanil provides insufficient sedation and is associated with a high risk of chest wall rigidity in preterm neonates.

Does Remifentanil Have a Place for Sedation in the Case of Endotracheal Intubation or Minimally Invasive Surfactant Therapy in Neonates?

“…We agree with de Kort et al [1] that a fast bolus of remifentanil followed by a saline flush in 30 s carries an increased risk of chest wall rigidity. However, we hypothesize that a slower administration over 60 s, as done in the previous studies, or even a continuous administration during laryngoscopy would likely decrease the rate of chest rigidity.…”

“…We recently read with great interest the paper by de Kort et al [1] which evaluated a premedication protocol for preterm neonates undergoing an INSURE procedure with remifentanil, and wanted to provide you with some critical feedback based on our experience in the field. The primary outcome measure of this single-center study was the quality of sedation by remifentanil, defined as the combination of an adequate sedation score, adequate intubation conditions, and the absence of side effects.…”

“…The primary outcome measure of this single-center study was the quality of sedation by remifentanil, defined as the combination of an adequate sedation score, adequate intubation conditions, and the absence of side effects. Two periods were described by de Kort et al [1]. In the first period, they started with a fast bolus of 1 μg/kg of remifentanil followed by a saline flush in 30 s. The procedure could be repeated twice if necessary.…”

“…For these procedures, remifentanil as a single premedication is typically administered at doses ranging from 1 to 3 μg/kg administered over 60 s, with good quality of sedation and a lower rate of chest wall rigidity - between 0 and 13% [3,4,5,6]. In their study, de Kort et al [1] administered high cumulative doses of remifentanil for 9 patients (3 μg/kg for 6 patients, 4 μg/kg for 2 patients, and 5 μg/kg for 1 patient) in order to achieve effective sedation. The ineffectiveness of remifentanil at these doses is in contrast with the potent effect of this opioid described in previous studies [3,4,5,6].…”

Reply to the Letter to the Editor “Does Remifentanil Have a Place for Sedation in the Case of Endotracheal Intubation or Minimally Invasive Surfactant Therapy in Neonates?”

“…We welcome the interest shown by Chollat et al [1] in our article on remifentanil as an induction agent for the INSURE procedure in preterm neonates [2]. We thank the authors for their critical feedback from their experience in the field.…”