Using Paralytic as Part of Premedication for Elective Intubation of Premature Neonates May Result in Transient Impairment of Ventilation

Chandrasekharan, Praveen; Nrusimha, Ananya; Rawat, Munmun; Lakshminrusimha, Satyanarayana

doi:10.1055/s-0038-1635092

Cited by 3 publications

(2 citation statements)

References 4 publications

(7 reference statements)

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“…Deeper systemic desaturation observed in the SufTrac group might also be due to the decrease in lung residual capacity due to the use of a muscle-blocker (atracurium) (6), while propofol is known to preserve spontaneous ventilation. The higher TcPCO 2 in this group is consistent with this hypothesis and was previously reported in other studies using muscular-blockers prior to neonatal intubation (6, 32).…”

Section: Discussionsupporting

confidence: 93%

Cerebral Oxygenation During Neonatal Intubation–Ancillary Study of the Prettineo–Study

et al. 2019

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Purpose: This study aimed to describe cerebral Near InfraRed Spectroscopy (NIRS) profiles during neonatal intubation using two different premedication regimens. Methods: Neonates requiring non-emergency intubation were enrolled in an ancillary study, conducted in two French Neonatal Intensive Care Units participating in a larger on-going multicenter, double blind, randomized, controlled trial. Patients were randomly assigned to the “atropine-propofol” (Prop) group or the “atropine-atracurium-sufentanil” (SufTrac) group. Regional cerebral oxygen saturation (rScO 2 ), pulse oxymetry (SpO 2 ), mean arterial blood pressure (MABP), and transcutaneous partial pressure of carbon dioxide (TcPCO 2 ) were collected at 9 predefined time points from 1 min before to 60 min after the first drug injection. The two primary outcomes were a decrease in rScO 2 value >20% from baseline and a decrease in fractional cerebral tissue oxygen extraction (FTOE) value >10% from baseline, at any time point. Secondary outcomes included physiological parameters changes over time and correlations between mean arterial blood pressure, and FTOE at different time points. Descriptive results were obtained and exploratory statistical analyses were performed for 24 included patients. Results: rScO 2 decreased in 5/11 (46%) infants from the Prop group and 10/13 (77%) from the SufTrac group ( p = 0.11); FTOE decreased in 10/11 (91%) infants from the Prop group, and 12/13 (92%) from the SufTrac group ( p = 0.90). rScO 2 values decreased over time in both groups, whereas FTOE's pattern appeared more stable. SpO 2 and transcutaneous TcPCO 2 seemed more preserved in the Prop group while MABP seemed more preserved in the SufTrac group. No important correlation was observed between MABP and FTOE (r = 0.08 to 0.12 across the time points). Conclusion: Our results suggest a frequent decrease in cerebral oxygenation without obvious impairment in cerebral autoregulation during neonatal intubation with premedication. This study confirms the feasibility and the informative value of cerebral NIRS monitoring in this setting. Clinical Trial Registration: www.ClinicalTrials.gov , identifier NCT02700893.

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Section: Discussionsupporting

confidence: 93%

Cerebral Oxygenation During Neonatal Intubation–Ancillary Study of the Prettineo–Study

et al. 2019

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“…For planned non-urgent intubations, many clinicians prefer to use a combination of a short-acting opiate, muscle relaxant and atropine to maximise comfort [146] and improve chances of successful intubation [147]. Longer-acting muscle relaxants like vecuronium may increase the need for ventilation and should not be used [148]. Routine sedation of ventilated neonates with opiates or midazolam is not supported by evidence [149, 150].…”

Section: Pain and Sedationmentioning

confidence: 99%

European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update

et al. 2019

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As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of “European Guidelines for the Management of RDS” by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.

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Premedication before laryngoscopy in neonates: Evidence-based statement from the French society of neonatology (SFN)

Durrmeyer

Walter-Nicolet²,

Chollat³

et al. 2023

Front. Pediatr.

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ContextLaryngoscopy is frequently required in neonatal intensive care. Awake laryngoscopy has deleterious effects but practice remains heterogeneous regarding premedication use. The goal of this statement was to provide evidence-based good practice guidance for clinicians regarding premedication before tracheal intubation, less invasive surfactant administration (LISA) and laryngeal mask insertion in neonates.MethodsA group of experts brought together by the French Society of Neonatology (SFN) addressed 4 fields related to premedication before upper airway access in neonates: (1) tracheal intubation; (2) less invasive surfactant administration; (3) laryngeal mask insertion; (4) use of atropine for the 3 previous procedures. Evidence was gathered and assessed on predefined questions related to these fields. Consensual statements were issued using the GRADE methodology.ResultsAmong the 15 formalized good practice statements, 2 were strong recommendations to do (Grade 1+) or not to do (Grade 1−), and 4 were discretionary recommendations to do (Grade 2+). For 9 good practice statements, the GRADE method could not be applied, resulting in an expert opinion. For tracheal intubation premedication was considered mandatory except for life-threatening situations (Grade 1+). Recommended premedications were a combination of opioid + muscle blocker (Grade 2+) or propofol in the absence of hemodynamic compromise or hypotension (Grade 2+) while the use of a sole opioid was discouraged (Grade 1−). Statements regarding other molecules before tracheal intubation were expert opinions. For LISA premedication was recommended (Grade 2+) with the use of propofol (Grade 2+). Statements regarding other molecules before LISA were expert opinions. For laryngeal mask insertion and atropine use, no specific data was found and expert opinions were provided.ConclusionThis statement should help clinical decision regarding premedication before neonatal upper airway access and favor standardization of practices.

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Using Paralytic as Part of Premedication for Elective Intubation of Premature Neonates May Result in Transient Impairment of Ventilation

Cited by 3 publications

References 4 publications

Cerebral Oxygenation During Neonatal Intubation–Ancillary Study of the Prettineo–Study

Cerebral Oxygenation During Neonatal Intubation–Ancillary Study of the Prettineo–Study

European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update

Premedication before laryngoscopy in neonates: Evidence-based statement from the French society of neonatology (SFN)

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