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Premedication with paralysis improves intubation success and decreases adverse events in very low birth weight infants: a prospective cohort study



To characterize the impact of premedication with and without a paralytic agent on the safety of tracheal intubation (TI) in infants ≤1500 g.

Study design

A prospective observational cohort study between February 2015 and June 2017. The primary outcomes were associations between the use of different premedication regimens with number of TI attempts, TI adverse events (TIAEs), and changes in heart rate.


Data were collected on 237 TIs. Median postmenstrual age at intubation was 28 completed weeks and weight was 953 g. Premedication with a paralytic was associated with fewer intubation attempts compared to premedication without a paralytic (p = 0.037). Premedication with a paralytic was associated with fewer TIAEs (p < 0.001) and less bradycardia compared to the other two regimens (p = 0.003) compared to premedication without a paralytic.


Premedication with a paralytic was associated with fewer intubation attempts, fewer TIAEs, and less bradycardia. Premedication with a paralytic may improve intubation safety in VLBWs.

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  1. Sawyer T, French H, Ades A, Johnston L. Neonatal-perinatal medicine fellow procedural experience and competency determination: results of a national survey. J Perinatol. 2016;36:570–4.

    Article  PubMed  CAS  Google Scholar 

  2. Haubner LY, Barry JS, Johnston LC, Soghier L, Tatum PM, Kessler D, et al. Neonatal intubation performance: room for improvement in tertiary neonatal intensive care units. Resuscitation. 2013;84:1359–64.

    Article  PubMed  Google Scholar 

  3. Hatch LD, Grubb PH, Lea AS, Walsh WF, Markham MH, Whitney GM, et al. Endotracheal intubation in neonates: a prospective study of adverse safety events in 162 infants. J Pediatr. 2016;168:62–66.e66

    Article  PubMed  Google Scholar 

  4. Sauer CW, Kong JY, Vaucher YE, Finer N, Proudfoot JA, Boutin MA, et al. Intubation Attempts increase the risk for severe intraventricular hemorrhage in preterm infants—a retrospective cohort study. J Pediatr. 2016;177:108–13.

    Article  PubMed  Google Scholar 

  5. Wallenstein MB, Birnie KL, Arain YH, Yang W, Yamada NK, Huffman LC, et al. Failed endotracheal intubation and adverse outcomes among extremely low birth weight infants. J Perinatol. 2016;36:112–5.

    Article  PubMed  CAS  Google Scholar 

  6. Foglia EE, Ades A, Napolitano N, Leffelman J, Nadkarni V, Nishisaki A. Factors associated with adverse events during tracheal intubation in the NICU. Neonatology. 2015;108:23–29.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Sawyer T, Foglia E, Hatch LD, Moussa A, Ades A, Johnston L, et al. Improving neonatal intubation safety: a journey of a thousand miles. J Neonatal Perinat Med. 2017;10:125–31.

    Article  CAS  Google Scholar 

  8. Roberts KD, Leone TA, Edwards WH, Rich WD, Finer NN. Premedication for non-emergent neonatal intubations: a randomized, controlled trial comparing atropine and fentanyl to atropine, fentanyl, and mivacurium. Pediatrics. 2006;118:1583–91.

    Article  PubMed  Google Scholar 

  9. Lemyre B, Cheng R, Gaboury I. Atropine, fentanyl and succinylcholine for non-urgent intubations in newborns. Arch Dis Child Fetal Neonatal Ed. 2009;94:F439–442.

    Article  PubMed  CAS  Google Scholar 

  10. Dempsey EM, Al Hazzani F, Faucher D, Barrington KJ. Facilitation of neonatal endotracheal intubation with mivacurium and fentanyl in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed. 2006;91:F279–282.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  11. Pereira e Silva Y, Gomez RS, Marcatto JeO, Maximo TA, Barbosa RF, Simões e Silva AC. Morphine versus remifentanil for intubating preterm neonates. Arch Dis Child Fetal Neonatal Ed. 2007;92:F293–294.

    Article  PubMed  Google Scholar 

  12. Ghanta S, Abdel-Latif ME, Lui K, Ravindranathan H, Awad J, Oei J. Propofol compared with the morphine, atropine, and suxamethonium regimen as induction agents for neonatal endotracheal intubation: a randomized, controlled trial. Pediatrics. 2007;119:e1248–1255.

    Article  PubMed  Google Scholar 

  13. Carbajal R, Eble B, Anand KJ. Premedication for tracheal intubation in neonates: confusion or controversy? Semin Perinatol. 2007;31:309–17.

    Article  PubMed  Google Scholar 

  14. Le CN, Garey DM, Leone TA, Goodmar JK, Rich W, Finer NN. Impact of premedication on neonatal intubations by pediatric and neonatal trainees. J Perinatol. 2014;34:458–60.

    Article  PubMed  CAS  Google Scholar 

  15. Kumar P, Denson SE, Mancuso TJ, Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine. Premedication for nonemergency endotracheal intubation in the neonate. Pediatrics. 2010;125:608–15.

  16. Muniraman HK, Yaari J, Hand I. Premedication use before non-emergent intubation in the newborn infant. Am J Perinatol. 2015;32:821–4.

    Article  PubMed  Google Scholar 

  17. Duncan HP, Zurick NJ, Wolf AR. Should we reconsider awake neonatal intubation? A review of the evidence and treatment strategies. Paediatr Anaesth. 2001;11:135–45.

    Article  PubMed  CAS  Google Scholar 

  18. Barrington KJ, Finer NN, Etches PC. Succinylcholine and atropine for premedication of the newborn infant before nasotracheal intubation: a randomized, controlled trial. Crit Care Med. 1989;17:1293–6.

    Article  PubMed  CAS  Google Scholar 

  19. Cook-Sather SD, Tulloch HV, Cnaan A, Nicolson SC, Cubina ML, Gallagher PR, et al. A comparison of awake versus paralyzed tracheal intubation for infants with pyloric stenosis. Anesth Analg. 1998;86:945–51.

    Article  PubMed  CAS  Google Scholar 

  20. Barrington KJ, Byrne PJ. Premedication for neonatal intubation. Am J Perinatol. 1998;15:213–6.

    Article  PubMed  CAS  Google Scholar 

  21. Oei J, Hari R, Butha T, Lui K. Facilitation of neonatal nasotracheal intubation with premedication: a randomized controlled trial. J Paediatr Child Health. 2002;38:146–50.

    Article  PubMed  CAS  Google Scholar 

  22. Raju TN, Vidyasagar D, Torres C, Grundy D, Bennett EJ. Intracranial pressure during intubation and anesthesia in infants. J Pediatr. 1980;96:860–2.

    Article  PubMed  CAS  Google Scholar 

  23. Friesen RH, Honda AT, Thieme RE. Changes in anterior fontanel pressure in preterm neonates during tracheal intubation. Anesth Analg. 1987;66:874–8.

    PubMed  CAS  Google Scholar 

  24. Marshall TA, Deeder R, Pai S, Berkowitz GP, Austin TL. Physiologic changes associated with endotracheal intubation in preterm infants. Crit Care Med. 1984;12:501–3.

    Article  PubMed  CAS  Google Scholar 

  25. Kelly MA, Finer NN. Nasotracheal intubation in the neonate: physiologic responses and effects of atropine and pancuronium. J Pediatr. 1984;105:303–9.

    Article  PubMed  CAS  Google Scholar 

  26. Cordero L, Hon EH. Neonatal bradycardia following nasopharyngeal stimulation. J Pediatr. 1971;78:441–7.

    Article  PubMed  Google Scholar 

  27. Brady JP, Tooley WH. Cardiovascular and respiratory reflexes in the newborn. Pediatr Clin North Am. 1966;13:801–21.

    Article  PubMed  CAS  Google Scholar 

  28. Bowman WC. Non-relaxant properties of neuromuscular blocking drugs. Br J Anaesth. 1982;54:147–60.

    Article  PubMed  CAS  Google Scholar 

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We would like to thank the neonatal fellows, attendings, nurse practitioners, hospitalists, and physician assistants in the NICUs at the University of Washington Medical Center and Seattle Children’s Hospital for their diligent completion of NEAR4NEOS data collection forms. We would also like to thank Hayley Buffman, Natalie Napolitano, and Akira Nishisaki at Children’s Hospital of Philadelphia for their work with the NEAR4NEOs database.

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Correspondence to Jeanne Krick.

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Krick, J., Gray, M., Umoren, R. et al. Premedication with paralysis improves intubation success and decreases adverse events in very low birth weight infants: a prospective cohort study. J Perinatol 38, 681–686 (2018).

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