Midazolam as premedication for less invasive surfactant administration: a prospective single-centre audit

Less invasive surfactant administration (LISA) is now a routinely practised method of administration of surfactant to neonates with respiratory distress. Many centres routinely use analgesia and/or sedation premedication prior to the LISA procedure; however, many different drugs are presently used, and the optimal premedication drug is unknown. We aimed to assess the efficacy and short-term safety of routine midazolam 50-100 µg/kg use as premedication for LISA.

This was a prospective single-centre audit of routine midazolam use as premedication before the LISA procedure over a 5.4-year period in a tertiary-level UK neonatal unit. We reviewed rates of procedural success, physiological stability and incidence of side effects as recorded contemporaneously on bespoke audit proformas following each LISA procedure. We also assessed numbers needing endotracheal intubation within 24 hours post the LISA procedure.

120 neonates received midazolam premedication for LISA and had a completed proforma in the study period. In 119/120 (99.2%) cases, the procedure was deemed successful. Rates of side effects overall were: surfactant reflux n=22 (18.5%); bradycardia (heart rate <100/min) n=19 (16.0%); apnoea n=29 (24.4%); oxygen desaturation (SaO₂<80%), n=56 (47.1%). Only 9/119 (7.6%) babies required endotracheal intubation and ventilation within 24 hours of their first LISA dose.

In our experience, routine midazolam premedication for LISA was associated with relatively low rates of physiological instability and a high rate of procedural success. Midazolam is a worthy potential candidate for formal study in comparative trials with other LISA premedication drugs, and against non-pharmacological LISA administration.