Assessment of atropine-sufentanil-atracurium anaesthesia for endotracheal intubation: an observational study in very premature infants

Abstract

BackgroundPremedication before neonatal intubation is heterogeneous and contentious. The combination of a short acting, rapid onset opioid with a muscle relaxant is considered suitable by many experts. The purpose of this study was to describe the tolerance and conditions of intubation following anaesthesia with atropine, sufentanil and atracurium in very premature infants.MethodsMonocentric, prospective observational study in premature infants born before 32 weeks of gestational age, hospitalised in the NICU and requiring semi-urgent or elective intubation. Intubation conditions, heart rate, pulse oxymetry (SpO2), arterial blood pressure and transcutaneous PCO2 (TcPCO2) were collected in real time during 30 minutes following the first drug injection. Repeated physiological measurements were analysed using mixed linear models.ResultsThirty five intubations were performed in 24 infants with a median post conceptional age of 27.6 weeks and a median weight of 850 g at the time of intubation. The first attempt was successful in 74% and was similar for junior (75%) and senior (74%) operators. The operator rated conditions as “excellent” or “good” in 94% of intubations. A persistent increase in TcPCO2 as compared to baseline was observed whereas other vital parameters showed no significant variations 5, 10, 15 and 30 minutes after the first drug injection. Eighteen (51%) desaturations (SpO2 less than or equal to 80% for more than 60 seconds) and 2 (6%) bradycardia (heart rate less than100 bpm for more than 60 seconds) were observed.ConclusionThis drug combination offers satisfactory success rate for first attempt and intubation conditions for the operator without any significant change in heart rate and blood pressure for the patient. However it is associated with frequent desaturations and a possible persistent hypercapnia. SpO2 and PCO2 can be significantly modified during neonatal intubation and should be cautiously followed in this high-risk population.

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

“…1). Frequent blood gases and noninvasive CO 2 monitoring were needed to stabilize these infants along with escalating ventilation settings (pressures/change of ventilation modes) to optimize ventilation similar to the experience reported by Durrmeyer et al 3 They speculated that this might be secondary to the loss of lung recruitment during intubation resulting in decreased compliance and need for higher ventilator settings post muscle relaxant use. Based on this experience, our institution has moved away from using paralytics routinely in premature neonates as part of premedication.…”

“…2 We did not use a vagolytic agent as atropine may be associated with side effects in preterm infants with hypoxic bradycardia and can cause tachycardia in some neonates after intubation. 3,4 On implementation, we found that preterm infants had transient respiratory impairment requiring increased respiratory support immediately after using premedication. Data collected on premature infants (<34 weeks) who underwent elective (n ¼ 30, using premedication) and emergent intubation (n ¼ 26, without premedication) between 2013 and 2015 in our NICU are shown in ►Table 1.…”

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

“…Laryngoscopy is undoubtedly uncomfortable, but when attempting LISA there is a better chance of achieving a success without sedation [67]. 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].…”

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update

“…Procedures such as venepuncture, intubation and MV all have potential to cause discomfort, and it is good practice to have mechanisms for evaluating pain using validated scoring systems [163]. Many clinicians prefer to use a combination of a short-acting opiate, muscle relaxant and atropine to maximize comfort and improve the chances of successful intubation [164]. However, there is a balance between ensuring comfort during laryngoscopy and not oversedating infants when trying to maintain them on non-invasive respiratory support [165].…”