Sedation of Newborn Infants for the INSURE Procedure, Are We Sure?

Abstract

Background. Neonatal intubation is a stressful procedure that requires premedication to improve intubation conditions and reduce stress and adverse physiological responses. Premedication used during the INSURE (INtubation, SURfactant therapy, Extubation) procedure should have a very short duration of action with restoration of spontaneous breathing within a few minutes. Aims. To determine the best sedative for intubation during the INSURE procedure by systematic review of the literature. Methods. We reviewed all relevant studies reporting on premedication, distress, and time to restoration of spontaneous breathing during the INSURE procedure. Results. This review included 12 studies: two relatively small studies explicitly evaluated the effect of premedication (propofol and remifentanil) during the INSURE procedure, both showing good intubation conditions and an average extubation time of about 20 minutes. Ten studies reporting on fentanyl or morphine provided insufficient information about these items. Conclusions. Too little is known in the literature to draw a solid conclusion on which premedication could be best used during the INSURE procedure. Both remifentanil and propofol are suitable candidates but dose-finding studies to detect effective nontoxic doses in newborns with different gestational ages are necessary.

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

“…A recent review on the use of premedication before intubation during the INSURE procedure showed no conclusive evidence on the optimal premedication but stated that remifentanil was probably the best candidate because of its unique pharmacological profile [4]. Remifentanil has an extremely brief action, high predictability, rapid onset and offset of action, and immediate recovery of the clinical effect after interruption of the administration [5].…”

Administering atropine and ketamine before less invasive surfactant administration resulted in low pain scores in a prospective study of premature neonates

“…Administering atropine and ketamine before LISA resulted in low pain scores and stable haemodynamic parameters, but relatively frequent adverse respiratory events. and strongly recommended for the intubation surfactant extubation procedure (9). Surprisingly, most studies on the LISA procedure did not include analgosedation (7), although awake laryngoscopy is known to be painful and associated with adverse events (10,11).…”

“…Uncertainties about the feasibility and the nature of administering premedication before this procedure are potential barriers to its wider implementation . Premedication is currently considered mandatory for all nonemergent neonatal intubations and strongly recommended for the intubation surfactant extubation procedure . Surprisingly, most studies on the LISA procedure did not include analgosedation , although awake laryngoscopy is known to be painful and associated with adverse events .…”

Analgesics and Sedatives in Critically Ill Newborns and Infants: The Impact on Long‐Term Neurodevelopment

“…This implies that neonates in the first week of postnatal life are at an increased risk for accumulation during either intermittent bolus or continuous administration of propofol, irrespective of the age or weight at birth . This PK knowledge was subsequently integrated in a propofol dose‐finding study (effective dose for 50% of patients, ED 50 ) through 8 patient strata (postmenstrual and postnatal age) to attain optimal effects for endotracheal intubation in neonates for the INSURE (intubation, surfactant administration, extubation) indication . It was determined that the ED 50 dose for preterm neonates varied between 0.7 and 1.4 mg/kg.…”

“…50 This PK knowledge was subsequently integrated in a propofol dose-finding study (effective dose for 50% of patients, ED 50 ) through 8 patient strata (postmenstrual and postnatal age) to attain optimal effects for endotracheal intubation in neonates for the INSURE (intubation, surfactant administration, extubation) indication. 51,52 It was determined that the ED 50 dose for preterm neonates varied between 0.7 and 1.4 mg/kg. This is significantly lower than initially suggested in literature.…”