Ellen de Kort

161 General discussion 9 Recommendations for future research Future research into the most effective and safe premedication strategy for endotracheal intubation should focus on the following aspects: • Dose-finding of fentanyl and remifentanil as bolus administration. • The use of remifentanil as a short continuous infusion. • Comparison of different muscle relaxants. • Comparison of different premedication strategies in different circumstances. • National and international collaboration and data-sharing regarding pharmacodynamic and pharmacokinetic data of different strategies. PREMEDICATION IN LESS INVASIVE SURFACTANT TECHNIQUES The use of premedication for the INSURE (INtubation – SURfactant – immediate Extubation) procedure has never been questioned. To make immediate extubation after the administration of surfactant possible, the respiratory depression that is often cause by premedication should be very short. Therefore, the premedication strategy should be carefully chosen. A systematic review showed there is not enough evidence on which premedication strategy is most effective and safe in the context of the INSURE procedure. 80 In two smalls studies, remifentanil and propofol as premedication for INSURE were evaluated. 53,57 Both seemed to be effective in providing adequate sedation, but the duration of effect on the respiratory drive was somewhat questionable. 80 In a pilot study on the use of remifentanil for this purpose, we were confronted with serious difficulties in achieving adequate sedation and an unacceptable high incidence of chest wall rigidity, necessitating a premature ending of our study. 55 We had to conclude that remifentanil, at least at a fast infusion rate of 30 seconds, was not suitable for this purpose. In the past years, to the best of our knowledge no new studies have appeared on the use of different premedication strategies prior to INSURE. The question which premedication strategy is best for this purpose, therefore, still remains unanswered. It is, however, undeniable that premedication should be used for the INSURE procedure. In the past decade, INSURE and also conventional surfactant administration during mechanical ventilation, have increasingly given way to LISA (Less Invasive Surfactant Administration). Comparable to endotracheal intubation and INSURE, LISA requires laryngoscopy, which is known to cause pain and distress. Despite this, LISA procedures