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  • Quality Improvement Article
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Standardizing premedication for non-emergent neonatal tracheal intubations improves compliance and patient outcomes

Journal of Perinatology volume 42, pages 132–138 (2022)Cite this article

Subjects

Abstract

Objective

We sought to standardize and improve compliance with evidence-based premedication for non-emergent neonatal intubations in two academic-affiliated Neonatal Intensive Care Units.

Study design

A multidisciplinary team created guidelines and electronic medical record order sets for intubation. Compliance with recommended premedication, number of intubation attempts, and frequency of bradycardia and desaturation were assessed.

Results

387 intubation procedures were reviewed. Provision of recommended premedication increased by 36% and 75% at the level III and IV units, respectively. Decreased frequency of bradycardia during intubation (p = 0.0003) occurred in the level III unit. A reduction in number of intubation attempts (p ≤ 0.001), improvement in first-attempt intubation success (p ≤ 0.001), and decreased frequency of bradycardia (p = 0.01) and desaturation (p = 0.02) during intubation occurred in the level IV unit.

Conclusions

This quality improvement initiative improved standardized premedication compliance and decreased adverse events associated with non-emergent neonatal intubations in two separate units.

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Fig. 1: Order Panel and Order Set for the electronic health record system.
Fig. 2: Monthly compliance with a preferred premedication regimen for non-emergent neonatal intubations.

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References

  1. Raju T, Suresh G, Higgins R. Patient safety in the context of neonatal intensive care: research and educational opportunities. Pediatric Res. 2011;70:109–15.

  2. Foglia E, Ades A, Napolitano N, Leffelman J, Nadkarni V, Nishisaki A. Factors associated with adverse events during tracheal intubation in the NICU. Neonatology. 2015;108:23–9.

    Article  Google Scholar 

  3. Hatch L, Grubb P, Lea A, Walsh W, Markham M, Whitney G, et al. Endotracheal intubation in neonates: a prospective study of adverse safety events in 162 infants. J Pediatrics. 2016;168:62–6.

    Article  Google Scholar 

  4. Sauer C, Kong J, Vaucher Y, Finer N, Proudfoot J, Boutin M, 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  Google Scholar 

  5. Wallenstein M, Birnie K, Arain Y, Yang W, Yamada N, Huffman L, et al. Failed endotracheal intubation and adverse outcomes among extremely low birth weight infants. J Perinatol. 2016;36:112–5.

    Article  CAS  Google Scholar 

  6. Pouppirt N, Nassar R, Napolitano N, Nawab U, Nishisaki A, Nadkarni V, et al. Association between video laryngoscopy and adverse tracheal intubation-associated events in the neonatal intensive care unit. J Pediatr. 2018;201:281–4.

    Article  Google Scholar 

  7. Sawyer T, Foglia E, Ades A, Moussa A, Napolitano N, Glass K, et al. Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates. Arch Dis Child Fetal Neonatal Ed. 2019;104:F461–466.

    Article  Google Scholar 

  8. Foglia E, Ades A, Sawyer T, Glass K, Singh N, Jung P, et al. Neonatal intubation practice and outcomes: an international registry study. Pediatrics. 2019;143:e20180902.

  9. Anand KJ. The International Evidence-Based Group for Neonatal Pain Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. 2011;155:173–80.

    Article  Google Scholar 

  10. Kumar P, Denson S, Mancuso T. Premedication for nonemergency endotracheal intubation in the neonate. Pediatrics. 2010;125:608–15.

  11. Barrington K. Premedication for endotracheal intubation in the newborn infant. Paediatrics Child Health. 2011;16:159–64.

    Article  Google Scholar 

  12. Ancora G, Lago P, Garetti E, Merazzi D, Levet P, Bellieni C, et al. Evidence-based clinical guidelines on analgesia and sedation in newborn infants undergoing assisted ventilation and endotracheal intubation. Acta Paediatrics. 2018;108:208–17.

    Article  Google Scholar 

  13. Roberts K, Leone T, Edwards W, Rich W, Finer N. Premedication for nonemergent neonatal intubations: a randomized, controlled trial comparing atropine and fentanyl to atropine, fentanyl, and mivacurium. Pediatrics. 2006;118:1583–91.

    Article  Google Scholar 

  14. Feltman D, Weiss M, Nicoski P, Sinacore J. Rocuronium for nonemergent intubation of term and preterm infants. J Perinatol. 2011;31:38–43.

    Article  CAS  Google Scholar 

  15. Krick J, Gray M, Umoren R, Lee G, Sawyer T. Premedication with paralysis improves intubation success and decreases adverse events in very low birth weight infants: a prospective cohort study. J Perinatol. 2018;38:681–6.

    Article  Google Scholar 

  16. Ghanta S, Abdel-Latif M, 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:e1248–55.

  17. de Kort E, Prins S, Reiss I, Willemsen S, Andriessen P, Weissenbruch. M, et al. Propofol for endotracheal intubation in neonates: a dose-finding trial. Arch Dis Child Fetal Neonatal Ed. 2020; https://doi.org/10.1136/fetalneonatal-2019-318474.

  18. Simons S, Lee R, Reiss I, Weissenbruch M. Clinical evaluation of propofol as sedative for endotracheal intubation in neonates. Acta Paediatrica. 2013;102:487–92.

    Google Scholar 

  19. Smits A, Thewissen L, Caicedo A, Naulaers G, Allegaert K. Propofol dose-finding to reach optimal effect for (semi-)elective intubation in neonates. J Pediatrics. 2016;179:54–60.

    Article  CAS  Google Scholar 

  20. Welzing L, Kribs A, Eifinger F, Huenseler C, Oberthuer A, Roth B. Propofol as an induction agent for endotracheal intubation can cause significant arterial hypotension in preterm neonates. Pediatr Anesthesia. 2010;20:585–90.

    Article  Google Scholar 

  21. Muniraman H, Yaari J, Hand I. Premedication use before nonemergent intubation in the newborn infant. Am J Perinatol. 2015;32:821–4.

    Article  Google Scholar 

  22. Sarkar S, Schumacher R, Baumgart S, Donn S. Are newborns receiving premedication before elective intubation? J Perinatol. 2006;26:286–9.

    Article  CAS  Google Scholar 

  23. National Emergency Airway Registry for Neonates (NEAR4NEOS). https://www.near4neos.org/.

  24. Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J. Research electronic data capture (REDCap) - a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 2009;42:377–81.

    Article  Google Scholar 

  25. Provost L, Murray S. The health care data guide: learning from data for improvement. San Francisco: Jossey-Bass, Publication; 2011.

  26. Mari J, Franczia P, Margas W, Rutkowski J, Bebrysz M, Bokiniec R, et al. International consensus is needed on premedication for non-emergency neonatal intubation after survey found wide-ranging policies and practices in 70 countries. Acta Paediatrica. 2019;00:1–7.

    Google Scholar 

  27. Hatch L, Grubb P, Lea A, Walsh W, Markham M, Maynord P, et al. Interventions to improve patient safety during intubation in the neonatal intensive care unit. Pediatrics 2016;138:e20160069.

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Authors and Affiliations

  1. University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA

    Rebecca Shay, Blair W. Weikel, Theresa Grover & James S. Barry

  2. Children’s Hospital Colorado, Section of Neonatology, Aurora, CO, USA

    Rebecca Shay, Blair W. Weikel, Theresa Grover & James S. Barry

Authors
  1. Rebecca Shay
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  2. Blair W. Weikel
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  3. Theresa Grover
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  4. James S. Barry
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Contributions

RS designed the study, collected data, analyzed the data and wrote the manuscript. BW analyzed the data, created tables, and helped to write the manuscript. TG and JB designed the study and helped to write the manuscript. The authors acknowledge the expertise and input from the multidisciplinary care team at the University Colorado Hospital NICU and the Children’s Hospital Colorado NICU including nursing, respiratory therapy, pharmacy, advanced practiced providers, resident physicians, fellow physicians and faculty.

Corresponding author

Correspondence to Rebecca Shay.

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The authors declare no competing interests.

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Shay, R., Weikel, B.W., Grover, T. et al. Standardizing premedication for non-emergent neonatal tracheal intubations improves compliance and patient outcomes. J Perinatol 42, 132–138 (2022). https://doi.org/10.1038/s41372-021-01215-2

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  • DOI: https://doi.org/10.1038/s41372-021-01215-2

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