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Premedication for tracheal intubation: a prospective survey in 75 neonatal and pediatric intensive care units
Lionel Simon1, Mohamed Trifa, Mustapha Mokhtari
1Réanimation Chirurgicale, Hôpital Cochin-Saint Vincent de Paul, Université Paris V, Paris, France.
Insights
Premedication for tracheal intubation is underused in neonates, despite its increasing use with patient age. This study found that premedication did not significantly improve intubation success or reduce adverse events in pediatric patients.
Area of Science:
- Pediatric Anesthesiology
- Neonatal Intensive Care
- Critical Care Medicine
Background:
- Tracheal intubation is a painful procedure in children and adults, potentially causing hemodynamic instability.
- The necessity of sedation for tracheal intubation in neonates remains debated, despite their sensitivity to pain.
Purpose of the Study:
- To investigate the current practices of premedication before tracheal intubation in neonatal and pediatric intensive care units.
- To determine the impact of premedication on the conditions and outcomes of tracheal intubation in pediatric patients.
Main Methods:
- A prospective survey was conducted over 10 days across 75 French neonatal and pediatric intensive care units.
- Data were collected via questionnaires for each tracheal intubation performed, studying 204 patients (140 neonates, 52 infants, 12 children).
Main Results:
- Premedication use varied significantly by age: 37.1% for neonates, 67.3% for infants, and 91.7% for children.
- Premedication was less common in the youngest and smallest neonates. Midazolam was common in neonates, propofol in children.
- Premedication did not significantly improve intubation success rates or reduce adverse events like hypoxemia and bradycardia.
Conclusions:
- Premedication use for tracheal intubation is limited in neonates and increases with patient age.
- Midazolam may not be optimal for improving neonatal and infant intubation conditions.
- Experienced operators are crucial for successful tracheal intubation; less experienced staff require support.
Objective:
In children, like in adults, tracheal intubation is a painful procedure that may induce hypertension, tachycardia, and other undesirable hemodynamic disorders. Although premature neonates are very sensitive to pain and vulnerable to its long-term effects, the need for sedation before tracheal intubation is still discussed in neonatal units. Our objective was to investigate the practice of premedication before tracheal intubation in neonatal and pediatric units and determine the influence of premedication on intubating conditions.
Design:
We performed a 10-day prospective survey in 75 neonatal and pediatric intensive care units among the 98 licensed in France. A questionnaire was completed for each intubation performed in each surveyed unit.
Subjects:
A total of 204 patients were studied: 140 neonates, 52 infants, and 12 children.
Main Results:
Data on 204 tracheal intubations were collected from 223 that were performed during the study period (participation rate, 91.4%). Premedication was used before intubation for 37.1%, 67.3%, and 91.7% of neonates, infants, and children, respectively (p <.0001). In the subgroup of neonates, premedication was particularly rare for the youngest and the smallest infants. Midazolam was the principle hypnotic used in neonates, whereas propofol was mainly used in children. Opioids or muscle relaxants were used in 16.2% and 4.4% of the patients, respectively. A low success rate and a high incidence of hypoxemia and bradycardia were correlated with the inexperience of the operator. Premedication did not significantly influence either the success rate or the undesirable events associated with tracheal intubation.
Conclusion:
Use of premedication before tracheal intubation is limited in neonates and increases according to the age of the patient. Midazolam does not seem to be an accurate choice to improve intubating conditions in neonates and infants. Because tracheal intubation is a technique that requires a skill only developed by regular practice, operators who have limited experience with intubating children should be supported by senior operators.
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