Ellen de Kort

149 General discussion 9 NEED FOR PREMEDICATION USE The multiple intubation attempts that are often needed for successful intubation in neonates are not without consequences. Exposing neonates to multiple intubation attempts is associated with adverse events on the short as well as on the long term. Multiple intubation attempts are related to a higher frequency of intubation related adverse events and severe oxygen desaturations, 12 with each additional intubation attempt doubling the odds for these adverse events. 1,10 Besides this, multiple intubation attempts have been related to the occurrence of intraventricular hemorrhage. Sauer et al. showed that in preterm infants with a birth weight less than 750 gram, severe intraventricular hemorrhage was almost 28 times more likely to develop in infants who were exposed to 3 or more intubation attempts. 13 On the long term, multiple intubation attempts have been linked to neurodevelopmental impairment in preterm infants. Wallenstein et al. showed that the odds for developing neurodevelopmental impairment were almost doubled when exposed to multiple intubation attempts compared to successful intubation at the first attempt. 14 Both studies are limited by their retrospective nature, the relatively small sample size and the lack of information regarding illness severity of the included patients. Further research to elucidate a causal relationship between an increased number of intubation attempts, and intraventricular hemorrhage and neurodevelopmental impairment is necessary. The results, however, are enough to warrant caution exposing preterm infants to multiple intubation attempts. The possibilityof premedication decreasing the number of attempts needed for successful intubation has been known for several decades. 15-20 Recent studies have added evidence to this. Sawyer et al. demonstrated a relation between the use of sedatives or analgesics and paralytic premedication, and the number of intubation attempts. 12 Besides this, the use of paralytic premedication has been found to be independently associated with a decrease in the odds for intubation related adverse events. 1,9 This protective effect of paralytic premedication could not be confirmed by Hatch et al. 10 The frequency of paralytic premedication use in their study population, however, could have been too low to capture any beneficial effect. Added to the already existing evidence, the results of these recent studies again stress the need for appropriate premedication prior to endotracheal intubation. The results also suggest that the specific use of paralytic premedication could improve patient safety during the procedure. The need for using premedication prior to endotracheal intubation is not new. The harmful effects of awake intubation and the possibility to reduce or eliminate these harmful effects by using premedication are known for decades. 15-18,20-24 Also the recommendation to use