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Editor—We were very interested in the recent papers by Bhutada et al 1and Whyte et al 2 on the use of premedication for semielective intubation in neonates. It is now well accepted that term and preterm neonates tolerate awake intubation poorly, often exhibiting hypoxia, bradycardia, and systemic and intracranial hypertension during nasotracheal or orotracheal intubation.3 ,4 Analgesia and sedation are still used infrequently in nurseries for intubation and other “routine”, but invasive, therapeutic or diagnostic procedures.5
We recently performed a randomised, double blind, placebo controlled trial to assess whether sedation with midazolam in premature infants would improve physiological stability and the success rate of endotracheal intubation. Eight premature infants underwent 16 intubation procedures after being randomly assigned to one of three groups: I (n = 3), the control group, received placebo only; II (n = 6) received atropine and placebo; III (n = 7) received atropine and midazolam. Infants could be randomised again to a different group after completion of each intubation procedure. Heart rate, blood pressure, and oxyhaemoglobin saturation were recorded at 10 minute intervals for each infant. The study was terminated and the data reviewed early because of concerns over adverse events. The number of episodes of oxyhaemoglobin desaturation around the time of intubation was significantly greater in group III (86%) than in group I (0%; p = 0.01). Cardiopulmonary resuscitation was required in 29% of group III compared with 0% of group II (p = 0.16).
In our trial, premature infants who received midazolam were at increased risk of oxyhaemoglobin desaturation during tracheal intubation. There was also a trend toward an increased need for cardiopulmonary resuscitation in these infants. Although regrettably underpowered because of early termination, our study indicates caution in the use of midazolam as routine premedication for tracheal intubation in premature infants. Further investigation with a larger number of infants is needed to clarify its safety and efficacy profile.
Although we agree that an important goal in neonatal medicine is to minimise pain and stress, more information is needed on the effects of intravenous anaesthetic agents, such as thiopental and methohexital,6 in both stable and unstable preterm neonates before these medications can be recommended for routine use. Further randomised controlled trials are needed to help formulate specific premedication guidelines for the variety of noxious procedures that infants undergo in neonatal intensive care units.