Premedication practices for tracheal intubation in neonates transported by French medical transport teams: a prospective observational study

Abstract

ObjectivesPremedication practices for neonatal tracheal intubations have not yet been described for neonatal transport teams. Our objective is to describe the use of sedation/analgesia (SA) for tracheal intubations and to assess its tolerance in neonates transported by medical transport teams in France.SettingThis prospective observational study was part of the EPIPPAIN 2 project and collected around-the-clock data on SA practices in neonates intubated by all five paediatric medical transport teams of the Paris region during a 2-month period. Intubations were classified as emergent, semiemergent and non-emergent. Sedation level and conditions of intubation were assessed with the Tonus, Reactivity, Awareness and Conditions of intubation to Help in Endotracheal intubation Assessment (TRACHEA score). The scores range from 0 to 10 representing an increasing ladder from adequate to inadequate sedation, and from excellent to very poor conditions of intubation.Participants40 neonates intubated in 28 different centres.ResultsThe mean (SD) age was 34.9 (3.9) weeks, and 62.5% were intubated in the delivery room. 30/40 (75%) of intubations were performed with the use of SA. In 18/30 (60.0%) intubations performed with SA, the drug regimen was the association of sufentanil and midazolam. Atropine was given in 19/40 intubations. From the 16, 21 and 3 intubations classified as emergent, semiemergent and non-emergent, respectively, 8 (50%), 19 (90.5%) and 3 (100%) were performed with SA premedication. 79.3% of intubations performed with SA had TRACHEA scores of 3 or less. 22/40 (55%) infants had at least one of the following adverse events: muscle rigidity, bradycardia below 100/min, desaturation below 80% and nose or pharynx–larynx bleeding. 7/24 (29.2%) of those who had only one attempt presented at least one of these adverse events compared with 15/16 (93.8%) of those who needed two or more attempts (p<0.001).ConclusionSA premedication is largely feasible for tracheal intubations performed in neonates transported by medical transport teams including intubations judged as emergent or semiemergent.Trial registration number NCT01346813; Results.

Premedication before laryngoscopy in neonates: Evidence-based statement from the French society of neonatology (SFN)

“…Pain and comfort : Adequate sedation before intubation (TRACHEA score≤1 ( 14 )) was significantly more frequent in the nMDZ group. Adequate comfort during intubation [FANS score <4 ( 43 )] was comparable in both groups.…”

“…Additional information : In 2 prospective observational studies, the combination of midazolam with a fast-acting opioids (sufentanil in one study, fentanyl in the other) was associated with good intubation conditions and proper sedation and analgesia ( 14 , 67 ).…”

“…Intubation conditions : The combination of adequate pre-intubation sedation (TRACHEA score≤1 ( 14 )) and adequate comfort during intubation [FANS score <4 ( 43 )] was statistically more frequent in the nMDZ group.…”

“…The conditions of intubation, evaluating the infant's tone and reactivity on the one hand, and the relaxation of the jaw, vocal cords opening and thoracic movements during laryngoscopy on the other hand, would make it possible to appreciate the effectiveness or not of the molecules and doses used. The TRACHEA score ( 14 ), the Intubation Readiness Score (IRS) ( 111 ) and the Viby-Mogensen score ( 112 ) are useful tools to measure the depth of sedation of the newborn. Finally, rigorous long-term follow-up of neonates included in research protocols evaluating premedication should address concerns about the neurodevelopmental effects of sedative and analgesic molecules used ( 87 ).…”

“…Nevertheless, practices remain very heterogeneous and awake intubation remains common in many neonatal departments (14)(15)(16), especially in the delivery room (17). Regarding the LISA or MIST methods, premedication practices are also very heterogeneous from one country or unit to another (18)(19)(20)(21)(22).…”