Dear Editor
With great interest we read the paper by Whyte et al regarding the
practice of premedication before intubation in UK neonatal units.[1]
Their finding that only 37% of the units gave any sedation before
intubation is worrysome in view of the known physiologic responses to
awake intubation.[2-4] However, one potential bias in their study design
was not discussed.
Since the information regarding this subject was
derived from telephonic interviews with the sister in charge of the unit
the results might merely reflect the policy of the unit as perceived by
this person and not the practice of the individual neonatologist
performing or supervising the intubation. Whether this would result in
underscoring or overscoring on the subject remains to be answered.
In our
experience sustantial interindividual variation exists among
neonatologists in the use of premedication before intubation of neonates.
In March of 1999 we performed a written survey among all neonatologists
and fellows working on each of the 10 neonatal intensive care units
(NICUs) in The Netherlands. The response rate was 77/87 (89%). Of the
respondents, 58 (76%) always gave some form of analgesia or sedation prior
to intubation, 13 (16%) only sometimes gave premedication, whereas 6 (8%)
never gave premedication. Of those who always gave premedication 33 (57%)
always combined the use of sedation with a muscle relaxant. Only 15 (17%)
used a written protocol for premedication.
Similar to Whyte’s results
great variation existed with regard to the choice and dose regimen of the
premedication. Morphine was the most widely used opioid, followed by
fentanyl and pethidine. Midazolam was the most popular sedative. On a few
occasions, ethomidate was mentioned as anaesthetic drug. Atropine was
sometimes used in patients with proven rapid onset of reflex bradycardia.
From these results it appears that premedication before intubation of
neonates is the rule rather than the exception in the NICU environment in
The Netherlands, although overscoring cannot be ruled out. When analysed
on a per NICU basis it was obvious that a great intra-NICU variation in
the practice of premedication exists.
Our results closely resemble those
of a recent survey among Canadian neonatologists which showed that in
approximately 75% of cases some premedication before intubation is used in
Canadian NICUs.[5] It would be interesting to see the results of a
survey among neonatologists in the UK.
The known physiological responses
to awake intubation include bradycardia, hypertension, hypoxemia,
laryngospasm and increased intracranial pressure (2-4). Moreover, awake
intubation requires more attempts, is more time-consuming and is
accompanied with more mucosal damage than premedicated intubation.[6]
Optimal prevention of these adverse effects probably requires the
combination of a vagolytic, an opioid and a muscle relaxant.[7]
Therefore, in our institution the combination of atropine (0.1 mg),
morphine (0.05-0.1 mg/kg) and vecuroniumbromide (0.05-0.1 mg/kg) is
routinely applied with great satisfaction. We fully agree with Whyte et al[1] that there is now sufficient evidence to support the routine practice
of premedication for elective intubation of neonates. Indeed, more
research is needed to investigate the optimal drug and dose regimen.
REFERENCES
1. Whyte S, Birrell G, Wyllie J: Premedication before intubation in
UK neonatal units. Arch Dis Child Fetal Neonatal Ed 2000;82:F38-F41.
2. Marshall TA, Deeder R, Pai S, Berkowitz GP, Austin TL: Physiologic
changes associated with endotracheal intubation in preterm infants. Crit
Care Med 1984; 12(6):501-3.
3. Kelly MA, Finer NN: Nasotracheal intubation in the neonate: Physiologic
responses and effects of atropine and pancuronium. J of Pediatrics
1984;105:303-9.
4. Friesen RH, Honda AT, Thieme RE: Changes in anterior fontanel pressure
in preterm neonates during tracheal intubation. Anesth Analg 1987;66:874-
8.
5. Vogel S, Gibbins S, Simmons B, Shah V: Premedication for endotracheal
intubation (EI) in neonates: A Canadian Perspective. Pediatric Research
2000;47(4):438A.
6. Oei J, Hari R, Lui K: Suxamethonium, atropine and morphine as induction
for neonatal nasotracheal intubation: A randomised controlled trial.
Pediatric Research 2000;47(4):421A.
7. Barrington KJ, Byrne PJ: Premedication for neonatal intubation. Am J of
Perinatol 1998;15(4):213-6.
Harry Molendijk, MD,
Neonatologist
Anneke Jaarsma, MD,
Neonatologist
Beatrix Children’s Hospital
Department of Pediatrics, Subdivision of Neonatology
University Hospital Groningen, P.O. Box 30001
9700 RB Groningen, The Netherlands
Dear Editor
With great interest we read the paper by Whyte et al regarding the practice of premedication before intubation in UK neonatal units.[1] Their finding that only 37% of the units gave any sedation before intubation is worrysome in view of the known physiologic responses to awake intubation.[2-4] However, one potential bias in their study design was not discussed.
Since the information regarding this subject was derived from telephonic interviews with the sister in charge of the unit the results might merely reflect the policy of the unit as perceived by this person and not the practice of the individual neonatologist performing or supervising the intubation. Whether this would result in underscoring or overscoring on the subject remains to be answered.
In our experience sustantial interindividual variation exists among neonatologists in the use of premedication before intubation of neonates. In March of 1999 we performed a written survey among all neonatologists and fellows working on each of the 10 neonatal intensive care units (NICUs) in The Netherlands. The response rate was 77/87 (89%). Of the respondents, 58 (76%) always gave some form of analgesia or sedation prior to intubation, 13 (16%) only sometimes gave premedication, whereas 6 (8%) never gave premedication. Of those who always gave premedication 33 (57%) always combined the use of sedation with a muscle relaxant. Only 15 (17%) used a written protocol for premedication.
Similar to Whyte’s results great variation existed with regard to the choice and dose regimen of the premedication. Morphine was the most widely used opioid, followed by fentanyl and pethidine. Midazolam was the most popular sedative. On a few occasions, ethomidate was mentioned as anaesthetic drug. Atropine was sometimes used in patients with proven rapid onset of reflex bradycardia. From these results it appears that premedication before intubation of neonates is the rule rather than the exception in the NICU environment in The Netherlands, although overscoring cannot be ruled out. When analysed on a per NICU basis it was obvious that a great intra-NICU variation in the practice of premedication exists.
Our results closely resemble those of a recent survey among Canadian neonatologists which showed that in approximately 75% of cases some premedication before intubation is used in Canadian NICUs.[5] It would be interesting to see the results of a survey among neonatologists in the UK.
The known physiological responses to awake intubation include bradycardia, hypertension, hypoxemia, laryngospasm and increased intracranial pressure (2-4). Moreover, awake intubation requires more attempts, is more time-consuming and is accompanied with more mucosal damage than premedicated intubation.[6] Optimal prevention of these adverse effects probably requires the combination of a vagolytic, an opioid and a muscle relaxant.[7] Therefore, in our institution the combination of atropine (0.1 mg), morphine (0.05-0.1 mg/kg) and vecuroniumbromide (0.05-0.1 mg/kg) is routinely applied with great satisfaction. We fully agree with Whyte et al[1] that there is now sufficient evidence to support the routine practice of premedication for elective intubation of neonates. Indeed, more research is needed to investigate the optimal drug and dose regimen.
REFERENCES
1. Whyte S, Birrell G, Wyllie J: Premedication before intubation in UK neonatal units. Arch Dis Child Fetal Neonatal Ed 2000;82:F38-F41.
2. Marshall TA, Deeder R, Pai S, Berkowitz GP, Austin TL: Physiologic changes associated with endotracheal intubation in preterm infants. Crit Care Med 1984; 12(6):501-3.
3. Kelly MA, Finer NN: Nasotracheal intubation in the neonate: Physiologic responses and effects of atropine and pancuronium. J of Pediatrics 1984;105:303-9.
4. Friesen RH, Honda AT, Thieme RE: Changes in anterior fontanel pressure in preterm neonates during tracheal intubation. Anesth Analg 1987;66:874- 8.
5. Vogel S, Gibbins S, Simmons B, Shah V: Premedication for endotracheal intubation (EI) in neonates: A Canadian Perspective. Pediatric Research 2000;47(4):438A.
6. Oei J, Hari R, Lui K: Suxamethonium, atropine and morphine as induction for neonatal nasotracheal intubation: A randomised controlled trial. Pediatric Research 2000;47(4):421A.
7. Barrington KJ, Byrne PJ: Premedication for neonatal intubation. Am J of Perinatol 1998;15(4):213-6.
Harry Molendijk, MD, Neonatologist
Anneke Jaarsma, MD, Neonatologist
Beatrix Children’s Hospital
Department of Pediatrics, Subdivision of Neonatology
University Hospital Groningen, P.O. Box 30001
9700 RB Groningen, The Netherlands