International consensus is needed on premedication for non‐emergency neonatal intubation after survey found wide‐ranging policies and practices in 70 countries

Abstract

This study evaluated whether practitioners from 70 countries used premedication for nonemergency neonatal intubation and identified attitudes and experience regarding the safety, side effects and efficiency of neonatal intubation. MethodsInvitations to take part in the survey were issued between 18 December 2018 and 4 February 2019 to users of neonatal-based websites and Facebook groups, members of professional societies and the authors of relevant publications in the last five years. ResultsWe analysed 718 completed questionnaires from 40 European and 30 non-European countries. Most of the responses were from neonatologists (69.6%) and paediatric or neonatal trainees (10.3%). In units without a protocol (31.6%), more than half of the practitioners (60.4%) chose premedication according to personal preference and 37.0% -11.9% of the overall respondents -did not use any drugs for non-emergency intubation. The most frequently reported drug combination was fentanyl, atropine and succinylcholine (6.8%). Most of the practitioners (78.5%) use the same drugs for term and preterm infants. Only 24.8% of the physicians were fully satisfied with their premedication practices. ConclusionNearly 12% of the respondents did not use premedication for non-emergency neonatal intubation. The wide-ranging policies and practices found among the respondents highlight the need for international consensus guidelines.

Premedication practices for neonatal tracheal intubation: Results from the EPIPPAIN 2 prospective cohort study and comparison with EPIPPAIN 1

“…1,2,4,39,40 Furthermore, it helps to decrease team stress, self-confidence for pediatric residents and fellows who perform this procedure less often than before. [8][9][10]21,41 Several limitations of this study should be considered. First, the data are 10-year-old and since 2011 practices have changed.…”

“…As shown by several declarative or observational studies, [17][18][19][20] the premedication rates for this procedure vary and increase slowly according to the countries and as years go by. 10 Three reasons may explain the difficulties to apply evidencebased medicine for this procedure, if nonurgent: the absence of a specific protocol, the difficulty to choose the most appropriate drug(s) for a given neonate, and the apparent uselessness and loss of time to apply a premedication for a trained practitioner. In our study, the presence of a protocol was an independent factor for the use of premedication before TI (OR [95% CI] = 4.80 [2.11-11.57]).…”

“…Mean (SD) GA at birth was 32.2 (4.6) weeks, and 73 (60%) of neonates were born before 33 weeks GA. Mean (SD) birth weight was 1783 (919) g. Median [25th-75th] 5-minute Apgar score and median [25th-75th] CRIB score were 9 [8][9][10] and 1 [0-3], respectively. Before their admission in ICU, 41 (34%) patients had already been intubated once (33 (80%) in the delivery room).…”

“…[5][6][7] Despite this guidance for the clinicians, the staff awareness of pain and its consequences in the neonatal period, and the publication in the last years of several studies on the possible drug combinations to use for this procedure, many neonatal and pediatric intensive care units (NICU/PICU) or individuals caregivers have not incorporated routine use of neonatal premedication into their practices. [8][9][10] In 2005, a large regional French longitudinal study (Epidemiology of Procedural Pain in Neonates (EPIPPAIN 1)) was conducted in 13 tertiary care centers in the region of Paris to collect epidemiological data on neonatal pain. 11 More than 60 000 painful or stressful procedures were collected in 430 neonates during the 2 months of study period with a total of 101 TI in 91 patients.…”

New techniques, new challenges—The dilemma of pain management for less invasive surfactant administration?

“…16 It had taken many years of research and education to reach a stage where the majority of neonatal units in developed countries had adopted the routine use of premedication for intubation, although practice has been varied with respect to the medication used. 17 However, in recent years, manipulation of the airway in "awake" preterm neonates is again becoming accepted practice. How can this be, when evidence has pointed to better outcomes with the use of premedication?…”