Standardizing premedication for non-emergent neonatal tracheal intubations improves compliance and patient outcomes

Shay, Rebecca; Weikel, Blair W; Grover, Theresa R.; Barry, James

doi:10.1038/s41372-021-01215-2

Cited by 9 publications

(9 citation statements)

References 23 publications

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“…As the difficulty increases, procedural experience is decreasing due to greater use of non-invasive ventilation, a reduction in working hours and significantly increased numbers of not just trainees but also consultants 17–20. In response to this, many strategies have been employed to try and either reduce the need for intubation,21–23 provide greater stability medically during the procedure24 25 or improve education and therefore proficiency of the intubator 26–36. Despite these strategies, intubation remains a problem and by comparison to adult studies our population show high rates of physiological instability and adverse events 5 37–40…”

Section: Discussionmentioning

confidence: 99%

Nasal high-flow therapy to Optimise Stability during Intubation: the NOSI pilot trial

Foran

Moore

Chathasaigh

et al. 2022

Arch Dis Child Fetal Neonatal Ed

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ObjectiveIn adult patients with acute respiratory failure, nasal high-flow (NHF) therapy at the time of intubation can decrease the duration of hypoxia. The objective of this pilot study was to calculate duration of peripheral oxygen saturation below 75% during single and multiple intubation attempts in order to inform development of a larger definitive trial.Design and settingThis double-blinded randomised controlled pilot trial was conducted at a single, tertiary neonatal centre from October 2020 to October 2021.ParticipantsInfants undergoing oral intubation in neonatal intensive care were included. Infants with upper airway anomalies were excluded.InterventionsInfants were randomly assigned (1:1) to have NHF 6 L/min, FiO21.0 or NHF 0 L/min (control) applied during intubation, stratified by gestational age (<34 weeks vs ≥34 weeks).Main outcome measuresThe primary outcome was duration of hypoxaemia of <75% up to the time of successful intubation,Results43 infants were enrolled (26 <34 weeks and 17 ≥34 weeks) with 50 intubation episodes. In infants <34 weeks’ gestation, median duration of SpO2of <75% was 29 s (0–126 s) vs 43 s (0–132 s) (p=0.78, intervention vs control). Median duration of SpO2 of<75% in babies ≥34 weeks’ gestation was 0 (0–32 s) vs 0 (0–20 s) (p=0.9, intervention vs control).ConclusionThis pilot study showed that it is feasible to provide NHF during intubation attempts. No significant differences were noted in duration of oxygen saturation of <75% between groups; however, this trial was not powered to detect a difference. A larger, higher-powered blinded study is warranted.

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Section: Discussionmentioning

confidence: 99%

Nasal high-flow therapy to Optimise Stability during Intubation: the NOSI pilot trial

Foran

Moore

Chathasaigh

et al. 2022

Arch Dis Child Fetal Neonatal Ed

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“…Surveys of providers have reported a perceived lack of benefit in improving intubation conditions and concern for medication errors or adverse drug events. 16 Providers in our unit echoed these responses and raised concerns regarding the ability to extubate following surfactant administration.…”

Section: Introductionmentioning

confidence: 95%

“…However, this practice has been inconsistently adopted in the US and international NICUs. 1 , 5 , 16 , 17 …”

Section: Introductionmentioning

confidence: 99%

“… 3 – 5 , 19 These studies demonstrated that written policies could aid staff in medication administration and reduce AEs without significant threat to clinical deterioration while awaiting medication. 3 , 4 , 8 , 19 , 20 However, despite the extensive body of literature supporting premedication, a 2020 survey of clinicians in 70 countries reported that 12% of practitioners do not use premedication, 32% of units do not have a standardized protocol, and 60% of providers chose premedication according to personal preference. 17 This report suggests that targeted facility-level education and protocol standardization is needed to improve compliance.…”

Section: Introductionmentioning

confidence: 99%

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Implementation of a Standardized Premedication Bundle to Improve Procedure Success for Nonemergent Neonatal Intubations

Diego

Malloy

Cox

et al. 2022

Pediatric Quality &Amp; Safety

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Introduction: The American Academy of Pediatrics recommends premedication for all nonemergent neonatal intubations, yet there remains significant variation in this practice nationally. We aimed to standardize our unit’s premedication practices for improved intubation success and reduced adverse events. Methods: The study workgroup developed educational material and protocol content. Process measures included premedication use, education, and audit form completion. Primary (success on first intubation attempt and adverse event rates) and secondary (trainee success) study outcomes are displayed using statistical process control charts and pre-post cohort comparisons. Results: Forty-seven percent (97/206) of nurses completed educational intervention before protocol release, with an additional 20% (42/206) following a staff reminder. Two hundred sixteen (216) patients were intubated per protocol with 81% (174/216) audit completion. Compared with baseline (n = 158), intubation attempts decreased from 2 (IQR, 1–2) to 1 (IQR, 1–2) (P = 0.03), and success on the first attempt increased from 40% (63/158) to 57% (124/216) (P < 0.01), with a notable improvement in trainee success from less than 1% (1/40) to 43% (31/72) (P < 0.01). The rate of severe and rare adverse events remained stable; however, there was a rise in nonsevere events from 30% (48/158) to 45% (98/216). The tachycardia rate increased with atropine use. There was no change in chest wall rigidity, number of infants unable to extubate following surfactant, or decompensation awaiting medications. Conclusions: Standardizing procedural care delivery reduced intubation attempts and increased the attempt success rate. However, this was accompanied by an increase in the rate of nonsevere adverse events.

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“…Alternative options to administer drugs are via the umbilical vein (direct puncture, not via a catheter), buccal or intranasal, however the interval to the onset of effect is potentially longer with the latter two ( 26 , 27 ). In addition, there is an important knowledge gap when it comes to the optimal treatment regimen (type, dosage) of the premedication ( 28 ).…”

Section: Sedate or Not Sedate?mentioning

confidence: 99%

Knowledge Gaps in the Fetal to Neonatal Transition of Infants With a Congenital Diaphragmatic Hernia

et al. 2021

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Clinical research for infants born with a congenital diaphragmatic hernia (CDH) has until recently mainly focused on advances in prenatal and postnatal treatment. However, during the early perinatal transition period there are major physiological adaptations. For most infants these changes will happen uneventfully, but for CDH infants this marks the beginning of serious respiratory complications. In recent years, there is emerging evidence that the clinical management during the perinatal stabilization period in the delivery room may influence postnatal outcomes. Herein, we discuss major knowledge gaps and novel concepts that aim to optimize fetal to neonatal transition for infants with CDH. One such novel and interesting approach is performing resuscitation with an intact umbilical cord, the efficacy of this procedure is currently being investigated in several clinical trials. Furthermore, close evaluation of neonatal physiological parameters in the first 24 h of life might provide early clues concerning the severity of lung hypoplasia and the risk of adverse outcomes. We will provide an overview of trending concepts and discuss potential areas for future research.

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Standardizing premedication for non-emergent neonatal tracheal intubations improves compliance and patient outcomes

Cited by 9 publications

References 23 publications

Nasal high-flow therapy to Optimise Stability during Intubation: the NOSI pilot trial

Nasal high-flow therapy to Optimise Stability during Intubation: the NOSI pilot trial

Implementation of a Standardized Premedication Bundle to Improve Procedure Success for Nonemergent Neonatal Intubations

Knowledge Gaps in the Fetal to Neonatal Transition of Infants With a Congenital Diaphragmatic Hernia

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