Ellen de Kort

160 Chapter 9 terminated prematurely, one of the reasons for this early termination being the difficulty in including patients in several of the age groups that we defined. 61 Smits et al. encountered the same difficulties in their propofol dose-finding study, with only three out of eight strata containing a sufficiently large sample size. 60 This inclusion difficulty can be explained by the significantly smaller number of neonateswith older gestational and postnatal ages that need endotracheal intubation. Awaiting further dose-finding studies, valuable information can be obtained by collecting data on effects and side effects in observational trials. Procedures need to be standardized and effect and side effect registration needs to be part of standard clinical care. To obtain sufficient patient numbers, neonatal centers should pursue collaboration and data-sharing on a national and international level. READY TO TACK – Towards an individualized premedication strategy Recommendations for clinical practice • The choice for a certain premedication strategy should be individualized in every patient, and should be dependent on factors such as gestational and postnatal age, underlying illness, reason for intubation, hemodynamic status and expected duration of mechanical ventilation. • In general, based on the available evidence, a strategy consisting of a short- acting opioid and a short-acting muscle relaxant seems most effective and safe. • The use of a muscle relaxant should be carefully considered in every patient. It should not be used in patients with a known or anticipated difficult airway and strongly discouraged in patients with severe respiratory insufficiency. • Because of difficulties in achieving effective sedation and the significant negative effects on blood pressure, propofol should not be used as a standard premedication regimen. It should only be used in very specific circumstances such as patients with a known or anticipated difficult airway or in whom only a short period of action of the premedication is absolutely required. • Propofol should not be used in patients with hemodynamic insufficiency and should be carefully considered in patients with a risk of hemodynamic instability. • When using propofol as premedication, it should be started in a low dose and be titrated according to the sedative effect, under close monitoring of blood pressure. • Caution is required with the use of remifentanil because of the high risk of chest wall rigidity.