Premedication for Nonemergent Neonatal Intubations: A Randomized, Controlled Trial Comparing Atropine and Fentanyl to Atropine, Fentanyl, and Mivacurium

Abstract

OBJECTIVE. The purpose of this work was to investigate whether using a muscle relaxant would improve intubation conditions in infants, thereby decreasing the incidence and duration of hypoxia and time and number of attempts needed to successfully complete the intubation procedure. PATIENTS/METHODS. This was a prospective, randomized, controlled, 2-center trial. Infants requiring nonemergent intubation were randomly assigned to receive atropine and fentanyl or atropine, fentanyl, and mivacurium before intubation. Incidence and duration of hypoxia were determined at oxygen saturation thresholds of ≤85%, ≤75%, ≤60%, and ≤40%. Videotape was reviewed to determine the time and number of intubation attempts and duration of action of mivacurium. RESULTS. Analysis of 41 infants showed that incidence of oxygen saturation ≤60% of any duration was significantly less in the mivacurium group (55% vs 24%). The incidence of saturation level of any duration ≤85%, 75%, and 40%; cumulative time ≥30 seconds; and time below the thresholds were not significantly different. Total procedure time (472 vs 144 seconds) and total laryngoscope time (148 vs 61 seconds) were shorter in the mivacurium group. Successful intubation was achieved in ≤2 attempts significantly more often in the mivacurium group (35% vs 71%). CONCLUSIONS. Premedication with atropine, fentanyl, and mivacurium compared with atropine and fentanyl without a muscle relaxant decreases the time and number of attempts needed to successfully intubate while significantly reducing the incidence of severe desaturation. Premedication including a short-acting muscle relaxant should be considered for all nonemergent intubations in the NICU.

Rocuronium for nonemergent intubation of term and preterm infants

“…Using the rocuronium dose of 0.5 mg kg À1 in our study, we found the duration of rocuronium to be much shorter (judged by gross motor movements); this difference is likely due to prolongation of duration of rocuronium by inhaled anesthetic agents in the aforementioned studies. 13 Prospective studies by Roberts et al 10 and Dempsey et al 11 showed successful facilitation of endotracheal intubation in neonatal populations similar to ours using mivacurium. Roberts et al 10 showed higher success rates for intubations by the second attempt, shorter duration of intubation procedure and decreased periods of desaturations.…”

“…[23][24][25] In addition to improving chances for successful intubation, paralytic agents are reported to attenuate adverse physiologic changes experienced during intubation attempts. Increased intracranial pressure, 2,3,26,27 increased systolic blood pressure 28 and longer duration of hypoxemia 10,29 have been reported in awake vs paralyzed neonatal intubations. The longterm consequences of these physiologic changes are not known.…”

“…Roberts et al 10 suggest that the reason premedication for intubation is not a widespread practice is because of lack of experience with these medications. Indeed, the drug best suited for the premedication of a neonate requiring intubation is not yet clear.…”

“…Nondepolarizing agents have replaced succinylcholine for similar paralytic properties (quick onset, short duration) and safer side effect profiles. Roberts et al 10 and Dempsey et al 11 reported successful facilitation of intubations with mivacurium, only to have this drug out of production in May 2006, shortly after their studies were published. The American Academy of Pediatrics' clinical report encouraging premedication for nonemergent intubation acknowledges the need for further study to establish an 'ideal' combination of agents.…”

“…However, serious potential adverse effects of succinylcholine have shifted interest to nondepolarizing neuromuscular blocking agents as safer alternatives. Two recent investigations report using mivacurium to safely and effectively facilitate nonemergent intubations in neonates; 10,11 unfortunately, this drug has since been discontinued. Rocuronium bromide (rocuronium) is another short-acting nondepolarizing agent that has been studied in older infant and pediatric populations, 12,13 but has not, to our knowledge, been studied in neonates for nonemergent intubation in the neonatal ICU (NICU).…”