Premedication for non-emergency intubation in the neonate

Endotracheal intubation is frequently performed in neonatal intensive care. This procedure is extremely distressing and painful, and it has the potential for causing laryngospasm, hemodynamic changes, a rise in intracranial pressure and a risk of hemorrhage and airway injury. These adverse changes can be attenuated by using premedication with analgesic, sedative and muscle-relaxant drugs. Premedication is standard practice for pediatric and adult Intubation, but in neonates the use of supportive pharmacological measures is still hotly debated, mainly in terms of the risks and benefits of using sedatives in unstable and premature newborn. In a recent UK survey, 90% of tertiary neonatal units reported the routine use of sedation prior to intubation with a combination of atropine plus an opioid (morphine or fentanyl), while 82% of such units routinely use a muscle-relaxant. In Italy, a recent survey (in press) showed that the majority of NICU (Neonatal Intensive Care Units) use the sa me association of drugs for analgesia and sedation before tracheal intubation, but "not always" in more than half of these units. There is clearly a persistent concern about using such drugs in preterm and newborn infants, despite recent evidence showing that premedication for elective neonatal intubation is safer and more effective than when the infant is awake. Here we review the effects of using analgesic and sedative drugs on intubation conditions (good jaw relaxation, open and immobile vocal cord, suppression of pharyngeal and laryngeal reflex), on the time it takes to complete the procedure successfully, on pain control and the potentially adverse effects of using combinations of drugs for sedation.