Ellen de Kort

150 Chapter 9 premedication for nonemergency endotracheal intubations in neonates already exists about 20 years. Intubationwithout premedication should only be performed in the delivery roomand in emergency situationswhen there is no intravenous access available. 25,26 Studies evaluating premedication use by asking clinicians about their premedication practices, showed that the routine use of premedication is about 90 to 100%. 27-30 Although these percentages are reassuring, the results of recent studies evaluating intubation practices in the NICU are alarming. The percentages of endotracheal intubations performedwithout premedication vary from 14% to as high as 38%. 1,2,9,10 These data might indicate that what clinicians say they do, is not always what they actually do in clinical practice. Whywas there such a high incidence of awake intubation in these studies? This question is difficult to answer, since all four abovementioned studies do not provide information regarding this issue. Intubations in the delivery room were not included in these studies and, therefore, to justify the absence of premedication according to the recommendation from 2001, it all should have been emergency intubations with no availability of intravenous access. Durrmeyer et al. previously showed that of all patients not receiving premedication before intubation, 85% did have an intravenous access at the time of intubation. 31 This indicates that there might be other reasons that keep neonatologists from administering premedication when intubating a neonate. Several factors could play a role in a neonatologists’ decision not to administer premedication, one of thembeing a risk for complications. However, serious complications after the administration of premedication before endotracheal intubation were not demonstrated by several randomized controlled trials. 32 In a multicenter observational study from France, Simon et al. showed that the rate of complications was not influenced by the use of premedication. 33 Insufficient evidence about efficacy and safety could be another reason for a neonatologist not to administer premedication. 34 Not only 20 years ago but even in the present time, premedication is less often used in smaller and younger neonates. 33,35,36 This apparent reluctance of neonatologists to administer premedication to extremely low birth weight infants could possibly be attributed to a greater concern about the side effects of premedication in these patients, or to the misconception that smaller and younger neonates would not need premedication. There is, however, no evidence that shows that extremely low birth weight infants have less adverse effects of awake intubation and experience less discomfort and pain. Just because these patients do not have the strength to struggle and fight the health care giver, does not mean they do not need premedication. Ozawa et al. also showed that premedication was less often used when surfactant administration and unstable hemodynamics were the intubation indications. 36 This could indicate concern for suppression of the respiratory drive and concerns for the effects of premedication on the patients’ hemodynamic status.