Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Association of full premedication on tracheal intubation outcomes in the neonatal intensive care unit: an observational cohort study

Journal of Perinatology (2023)Cite this article

Subjects

Abstract

Objective

Evaluate the association of short-term tracheal intubation (TI) outcomes with premedication in the NICU.

Study design

Observational single-center cohort study comparing TIs with full premedication (opiate analgesia and vagolytic and paralytic), partial premedication, and no premedication. The primary outcome is adverse TI associated events (TIAEs) in intubations with full premedication compared to those with partial or no premedication. Secondary outcomes included change in heart rate and first attempt TI success.

Results

352 encounters in 253 infants (median gestation 28 weeks, birth weight 1100 g) were analyzed. TI with full premedication was associated with fewer TIAEs aOR 0.26 (95%CI 0.1–0.6) compared with no premedication, and higher first attempt success aOR 2.7 (95%CI 1.3–4.5) compared with partial premedication after adjusting for patient and provider characteristics.

Conclusion

The use of full premedication for neonatal TI, including an opiate, vagolytic, and paralytic, is associated with fewer adverse events compared with no and partial premedication.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Get just this article for as long as you need it

$39.95

Learn more

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Flow diagram.
Fig. 2: Univariate outcomes according to premedication group.
Fig. 3: Multivariate analysis of primary and secondary outcomes comparing three premedication groups.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. 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 

  2. 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 [Internet]. 2018;38:681–6. http://www.nature.com/articles/s41372-018-0082-2

    Article  PubMed  Google Scholar 

  3. 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;108:23–9.

    Article  PubMed  Google Scholar 

  4. Ozawa Y, Ades A, Foglia EE, DeMeo S, Barry J, et al. for the National Emergency Airway Registry for Neonates (NEAR4NEOS) Investigators. Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events. J Perinatol [Internet]. 2019;39:848–56. http://www.nature.com/articles/s41372-019-0367-0

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  7. 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 J Calif Perinat Assoc. 2016;36:112–5.

    CAS  Google Scholar 

  8. 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:F279–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. 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 [Internet]. 2016;177:108–13. https://linkinghub.elsevier.com/retrieve/pii/S0022347616304176

    Article  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  11. 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 [Internet]. 2010;125:608–15. https://doi.org/10.1542/peds.2009-2863.

    Article  PubMed  Google Scholar 

  12. Byrne E. Should premedication be used for semi-urgent or elective intubation in neonates? Arch Dis Child [Internet]. 2005;91:79–83. https://doi.org/10.1136/adc.2005.087635.

    Article  Google Scholar 

  13. Ballabh P. Intraventricular hemorrhage in premature infants: mechanism of disease. Pediatr Res. 2010;67:1–8.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Glenn TJ, Grathwol MM, McClary JD, Wainwright RJ, Gorman SM, Rodriguez AM, et al. Decreasing time from decision to intubation in premedicated neonates: a quality improvement initiative. Pediatr Qual Saf [Internet]. 2019;4:e234 https://journals.lww.com/10.1097/pq9.0000000000000234

    Article  PubMed  Google Scholar 

  15. 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.e6.

    Article  PubMed  Google Scholar 

  16. Muniraman H, Yaari J, Hand I. Premedication use before nonemergent intubation in the newborn infant. Am J Perinatol [Internet]. 2015;32:821–4. https://doi.org/10.1055/s-0034-1543987.

    Article  PubMed  Google Scholar 

  17. Sarkar S, Schumacher RE, Baumgart S, Donn SM. Are newborns receiving premedication before elective intubation? J Perinatol J Calif Perinat Assoc. 2006;26:286–9.

    CAS  Google Scholar 

  18. Lemyre B, Cheng R, Gaboury I. Atropine, fentanyl and succinylcholine for non-urgent intubations in newborns. Arch Dis Child Fetal Neonatal Ed. 2009;94:F439–42.

    Article  CAS  PubMed  Google Scholar 

  19. Nishisaki A, Turner DA, Brown CA, Walls RM, Nadkarni VM, National Emergency Airway Registry for Children (NEAR4KIDS). et al. A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs. Crit Care Med. 2013;41:874–85.

    Article  PubMed  Google Scholar 

  20. Foglia EE, Ades A, Sawyer T, Glass KM, Singh N, Jung P, et al. Neonatal intubation practice and outcomes: an international registry study. Pediatrics [Internet] 2019;143:e20180902 https://doi.org/10.1542/peds.2018-0902.

    Article  PubMed  Google Scholar 

  21. Johnston L, Kwon SH. Moving from controversy to consensus: premedication for neonatal intubation. J Perinatol [Internet]. 2018;38:611–3. https://www.nature.com/articles/s41372-018-0115-x

    Article  PubMed  Google Scholar 

  22. COMMITTEE ON FETUS AND NEWBORN, Barfield WD, Papile LA, Baley JE, Benitz W, Cummings J, et al. Levels of neonatal care. Pediatr [Internet]. 2012;130:587–97. https://doi.org/10.1542/peds.2012-1999.

    Article  Google Scholar 

  23. Stevens TP, Harrington EW, Blennow M, Soll RF. Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev. 2007. https://doi.org/10.1002/14651858.CD003063.pub3.

  24. Sk H, Saha B, Mukherjee S, Hazra A. Premedication with fentanyl for less invasive surfactant application (LISA): a randomized controlled trial. J Trop Pediatr. 2022;68:fmac019.

    Article  PubMed  Google Scholar 

  25. Bohlin K, Gudmundsdottir T, Katz-Salamon M, Jonsson B, Blennow M. Implementation of surfactant treatment during continuous positive airway pressure. J Perinatol J Calif Perinat Assoc. 2007;27:422–7.

    CAS  Google Scholar 

  26. 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  CAS  PubMed  Google Scholar 

  27. Hodgson KA, Owen LS, Kamlin COF, Roberts CT, Newman SE, Francis KL, et al. Nasal high-flow therapy during neonatal endotracheal intubation. N Engl J Med [Internet]. 2022;386:1627–37. https://doi.org/10.1056/NEJMoa2116735.

    Article  PubMed  Google Scholar 

  28. Miller KE, Singh N. Association of multiple tracheal intubation attempts with clinical outcomes in extremely preterm infants: a retrospective single-center cohort study. J Perinatol Off J Calif Perinat Assoc. 2022. https://doi.org/10.1038/s41372-022-01406-5.

  29. Zimmerman KO, Smith PB, Benjamin DK, Laughon M, Clark R, Traube C, et al. Sedation, analgesia, and paralysis during mechanical ventilation of premature infants. J Pediatr [Internet]. 2017;180:99–104.e1. https://linkinghub.elsevier.com/retrieve/pii/S0022347616305224

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to thank the pediatric residents, neonatal fellows, advance practice providers, and attending neonatologists at the University of Washington Medical Center, Montlake NICU, for their timely completion of the NEAR4NEOS data collection forms. We also extend thanks to Hayley Buffman at the Children’s Hospital of Philadelphia for her commitment to neonatal intubation safety and maintenance of the NEAR4NEOS database.

Author information

Authors and Affiliations

  1. University of Washington School of Medicine and Seattle Children’s Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA

    Sara K. Neches, Rachel Umoren, Megan M. Gray & Taylor Sawyer

  2. University of Nebraska Medical Center, Department of Pediatrics, Division of Neonatology, Omaha, NE, USA

    Brianna K. Brei

  3. Children’s Hospital of Philadelphia. Department of Anesthesiology and Critical Care Medicine, Philadelphia, PA, USA

    Akira Nishisaki

  4. Children’s Hospital of Philadelphia. Department of Pediatrics, Division of Neonatology, Philadelphia, PA, USA

    Elizabeth E. Foglia

Authors
  1. Sara K. Neches
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brianna K. Brei
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rachel Umoren
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Megan M. Gray
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Akira Nishisaki
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Elizabeth E. Foglia
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Taylor Sawyer
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SKN was responsible for study concept, data form auditing, extracting, and analyzing data, interpretation of results, and report writing. BKB was responsible for unit protocol changes, data form auditing, and report edits. RU contributed to the interpretation of results and provided feedback on the report. MMG guided with statistical analysis and presentation of data and provided feedback on the report. TS provided feedback on the report and AN and EF were responsible for generating the NEAR4NEOS centralized repository for neonatal intubation safety data and provided feedback on the report.

Corresponding author

Correspondence to Sara K. Neches.

Ethics declarations

Competing interests

The authors have no financial disclosures or conflicts of interest. NEAR4NEOS has been supported by NICHD HD089151. There was no direct funding for this analysis.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Neches, S.K., Brei, B.K., Umoren, R. et al. Association of full premedication on tracheal intubation outcomes in the neonatal intensive care unit: an observational cohort study. J Perinatol (2023). https://doi.org/10.1038/s41372-023-01632-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1038/s41372-023-01632-5

Search

Advanced search

Quick links