Ellen de Kort

151 General discussion 9 Although these concerns are justified, awake intubation in these patients is probably not. Instead of not using premedication, the premedication strategy must be aligned with the indication for intubation and the underlying condition of the patient. In addition, the absence of guidelines for the use of premedication probably also plays a role. The presence of a clear local guideline regarding the use of premedication, also including types of drugs and dosages, could encourage neonatologists to use premedication. Finally, preparation times can be a factor withholding premedication use. 37 Studies have shown that preparation times can take up to 16 minutes. 38,39 This can be resolved by the use of pharmacy prepared prefilled syringes. READY TO TACK – Towards improvement in the use of premedication Recommendations for clinical practice • Previous and recent evidence has sufficiently shown the harmful effects of awake intubation in neonates. The need for using premedication should no longer be questioned. • There is no good reason to performendotracheal intubation in awake neonates, except when it concerns an emergency situation in which the endotracheal tube should be placed without any delay. • The unavailability of an intravenous access in itself should not be a contra- indication for the use of premedication. The possibility of stabilizing the patient with non-invasive ventilatory support or bag and mask ventilation to create time for providing an intravenous access should be considered. • The harmful effects of awake intubation apply to all neonates, regardless of age, underlying illness and clinical condition. Therefore, these factors should be taken into account when choosing the most appropriate premedication strategy, but should not be an absolute reason to perform awake intubation. • The use of premedication and the choice for a certain drug or combination of drugs should not be left at the discretion of the individual physician. Every neonatal unit should have a written guideline for the use of premedication in neonatal endotracheal intubation, whichmust describe specific premedication strategies for specific patient conditions. To eliminate preparation times, premedication should be readily available, for example in pharmacy prepared prefilled syringes.