Rapid Sequence Induction is Superior to Morphine for Intubation of Preterm Infants: A Randomized Controlled Trial

Abstract

RSI with the drugs used can be implemented as medication for semi-urgent intubation in preterm infants. Because of circulatory changes and neurophysiological depression found during and after the intubation in infants given morphine, premedication with morphine should be avoided.

Premedication for intubation with morphine causes prolonged depression of electrocortical background activity in preterm infants

“…In conclusion, our data show that morphine administration in very preterm infants is associated with prolonged cerebral depression, more discontinuous aEEG/EEG BG, and lack of SWC persisting for 24 h. In contrast, RSI premedication with thiopental and remifentanil resulted in shorter EEG depression and less extensive blood pressure changes in addition to the advantage of better intubation conditions with less effect on acute physiological parameters (19). Commonly used analgesic doses of morphine also had a neurodepressive effect lasting at least 6 h. Thus, drug effects must be considered when diagnostic EEGs are performed for assessment of brain function.…”

“…The electrocortical depression occurred independently of the blood pressure response. In our RCT, morphine premedication was associated with more pronounced aEEG/EEG depression and acute circulatory changes during and after intubation than the RSI combination of thiopental and remifentanil (19). However, prolonged effects of these premedications have not been studied in very preterm infants in a randomized study.…”

“…Written informed consent was obtained from both parents before enrollment. The study protocol and all the analyses were carried out in a blinded fashion (19).…”

“…In newborns, morphine is still frequently used despite its slow onset and long duration of action (17,18). Recently we demonstrated, in a randomized controlled trial (RCT) including preterm infants, that the intubation conditions were improved and the acute hemodynamic effects (heart rate and mean arterial blood pressure, MABP) on the infant were significantly milder after premedication with short-acting analgo-sedation including thiopental, remifentanil, and muscle relaxation (so called rapid sequence induction/intubation, RSI) vs. morphine (19). The advantages of short-acting analgo-sedation before intubation of newborn infants have previously been reported in a few other RCTs (13,(20)(21)(22).…”

Correction to: Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review

“…The in-vitro half-life and degradation rate did not differ between groups without any correlation to GA, indicating a high non-specific esterase activity already in very preterm infants. There are no PK data reported in preterm neonates, although remifentanil is increasingly used in this age group [167,168].…”