Ellen de Kort

153 General discussion 9 assessing sedation level. As a gold standard for example the Viby-Mogensen intubation score can be used, as we did in our validation of the IRS. 42,43 In addition, heel rubbing as a tactile stimulus should be reconsidered. For certain patients, this stimulus might not be strong enough to reflect the pain and stress of laryngoscopy and introducing the endotracheal tube into the nostril. The use of a stronger stimulus, however, might raise ethical issues. Finally, the interobserver variability of the IRS has not been previously assessed. Since significant interobserver variation in the firmness of heel rubbing as well as the interpretation of the motor reaction following heel rubbing is possible, future research should address this issue. READY TO TACK – Towards pursuing an adequate level of sedation Recommendations for clinical practice • After the administration of premedication, the level of sedation should be closely monitored by using objective scoring methods such as the Intubation Readiness Score. • Intubation should only be performed when an adequate level of sedation is reached. Additional medication to achieve adequate sedation should be administered whenever needed. Recommendations for future research • Possibilities for expanding the Intubation Readiness Score to increase its positive predictive value for adequate sedation level should be investigated. • The use of a stronger stimulus better reflecting the pain and discomfort that accompany the act of endotracheal intubation should be considered. • The issue of interobserver variability in applying the firm stimulus and judging the motor reaction to that stimulus should be addressed. THE USE OF DIFFERENT PREMEDICATION STRATEGIES The effectivity of a premedication strategy that consists of a vagolytic, an analgesic and a muscle relaxant is supported by several studies. The atropine-opioid-muscle relaxant combination has been shown to have a higher first attempt success rate and, as a consequence, a lower total number of attempts, compared to the combination of atropine and an opioid without a muscle relaxant. 34,44,45 Roberts et al. also showed that