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Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial
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  • Published on:
    Anesthesia in delivery room and respiratory drive
    • Christophe Milesi, Pediatrician Academic Montpellier hospital
    • Other Contributors:
      • Camille Brotelande, pediatrician
      • Julien Baleine, pediatrician
      • Sabine Durant, pediatrician
      • Gilles Cambonie, pediatrician


    Dear Editor
    We were honoured to read the kind comment from Dr Subhash C Shaw (1) concerning our article « Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial” by Milési et al published in Arch Dis Child Fetal Neonatal Ed 2018; 103: F221-F226.1 » (2).
    Dr Shaw rose several important questions:
    He questions the possibility to keep a good respiratory drive with an anaesthetic procedure in delivery room. At the time of this study (2012) we were not using the INSURE procedure. For two years we are using the “Less Invasive Ventilation (LISA)” with a sedation protocol. Our protocol is proposing either intra-venous (IV) KETAMINE (0.5 mg/kg) or intra-nasal (IN) (0.2 mg/kg) MIDAZOLAM if an IV line is unavailable. Keeping a good respiratory drive is a key issue with this new technique. Therefore the anaesthetic issue is a very challenging one. Several authors show that it was possible to insure a good sedation level while keeping a good respiratory drive (3-5). In our experience with LISA and IN MIDAZOLAM (personal data) the success rate defined by the absence of intubation within the first 72 hours occurred in 7/10 of the cases, which was similar to the one described in the literature with or without any sedation (3-6).
    There are still some controversies regarding MIDAZOLAM safety. This drug is widely used in Europe (7). The myoclonic movements are...

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    Conflict of Interest:
    None declared.
  • Published on:
    • Subhash C Shaw, Neonatologist Dept of Pediatrics, Armed Forces Medical College, Pune 411040. India
    • Other Contributors:
      • Arjun Kurup, Resident
      • Kannan Venkatnarayan, Neonatologist

    Dear Editor,
    We read with great interest the article “Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial” by Milési et al published in Arch Dis Child Fetal Neonatal Ed 2018; 103: F221-F226.1 We complement the authors for this well conducted randomized trial on a very important subject of sedation while neonatal intubation. Having gone through the article, we would like to add the following.
    The intubations done were all non-emergent, with the mean gestational age being 27.6 (24-34) and 28.3 (24-36) weeks in both the groups respectively. It will be interesting to know what percentage of infants underwent Intubation, Surfactant administration, Extubation (INSURE)2 and placed back on nasal CPAP. As good respiratory drive is an essential prerequisite for nasal CPAP, there are concerns for sedation while attempting INSURE.
    The other concern is about the safety of both the drugs used in neonatal particularly in preterm population. There are reports of paradoxical stimulation of central nervous system including myoclonic movements associated with administration of midazolam.3 There is also evidence to suggest midazolam administration leading to increased NICU stay and adverse neurological events.4 The oscillometric blood pressure measurement recorded intermittently as in this study might not capture continuous invasive blood pressure changes.
    Finally, as the article very succinctly explained that the dosage of keta...

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    Conflict of Interest:
    None declared.