Premedication for Neonates Requiring Nonemergency Intubation

Abstract

To the Editor Dr Durrmeyer and colleagues 1 investigated 173 neonates requiring nonemergent intubation in a multicenter, double-blind clinical trial, randomly assigning infants to receive atropine-propofol or atropine-atracuriumsufentanil before nasotracheal intubation. The authors reported that "the frequency of prolonged desaturation did not differ significantly [between groups]…. However, the study may have been underpowered to detect a clinically important difference."We would like to raise 2 points of concern regarding this study. First, the potential toxicity of general anesthetics like propofol administered to children receiving general anesthesia is controversial and has led to a warning from the US Food and Drug Administration (FDA). 2 We wonder whether anesthetic toxicity during intubation and sedation of neonates is relevant.Second, we would like to emphasize the occurrence of intraventricular hemorrhage. The authors stated that "the goal of premedication is to prevent pain, because multiple painful experiences in the neonatal period are associated with poor neurodevelopmental outcome." In this study, neonates were exposed to 2.5 mg/kg of propofol for infants weighing more than 1000 g and 1 mg/kg of propofol for those weighing less than 1000 g. Propofol has no analgesic properties, and we are concerned about whether this practice facilitates the occurrence of intraventricular hemorrhage, especially after Friesen et al 3 demonstrated that intracranial pressure increases by almost 200% during intubation. The difference in the number of intraventricular hemorrhages between groups (20.6% in the atropine-propofol group and 17.6% in the atropine-atracurium-sufentanil group; P = .87) may be underestimated due to the greater number of boys (69.5% vs 49.4%) and premature infants with lower median birth weight of 1130 g in the atropine-propofol group vs 1310 g in the atropine-atracurium-sufentanil group. Both parameters previously have been shown to be independent risk factors for intraventricular hemorrhage. 4,5 In our experience, the use of propofol without analgesia for tracheal intubation in neonates should only be recommended cautiously, although there might be a benefit in preservation of oxygen saturation immediately after intubation.