Ellen de Kort

152 Chapter 9 Recommendations for future research • To prevent the necessity of an intravenous access to administer premedication, future research should focus on the possibility of administering premedication via other routes, for example oral, nasal and buccal routes. ASSESSMENT OF PREMEDICATION EFFECT The administration of premedication is not a goal in itself. The aim of administering premedication is to provide an adequate level of sedation to provide comfort, minimalize pain, stress and physiological disturbances, and facilitate the procedure. Therefore, it is not only important to administer premedication but also to evaluate the effect and pursue an adequate sedation level before proceeding with the intubation procedure. In clinical practice, however, the level of sedation after the administration of premedication was often not assessed before intubation was started, or was assessed in a variable and subjective way. Objective validated scoring systems to assess the level of sedation in the neonatal population were not available. A literature search did, however, reveal three objective sedation assessment tools, which are all promising but need validation before they can be implemented into clinical practice. 40 We, therefore, developed an Intubation Readiness Score (IRS) to assess the level of sedation, that was based on the sedation score described by Naulaers et al. 41 Based on correlation of the IRS with the quality of intubation assessed by the intubation score of Viby-Mogensen, 42 the IRS was shown to accurately indicate the level of sedation during the intubation procedure in 85% of neonates. 43 The IRS is currently the best available easy to perform tool to evaluate the effect of premedication. In 85% of patients the actual level of sedation is well predicted by the IRS. In 15% of patients, however, sedation during the intubation was inadequate even though the IRS indicated otherwise. 43 This stresses the need for further developing and expanding the IRS to improve its accurateness. It must, however, be ensured that the score does not become too extensive and time consuming for use in the acute situation of endotracheal intubation. A possibility would be to expand the IRS with the relaxation score, also described by Naulaers et al. 41 This score assesses the muscle tone of the extremities on a 4-point scale. Incorporating this relaxation score into the IRS, might improve its accurateness in assessing the level of sedation. Further studies have to be performed to validate this expanded IRS, by comparing the IRS with a gold standard for