Ellen de Kort

163 General discussion 9 Recommendations for future research • Future research should focus on the most suitable premedication strategy for LISA, that should be very short-acting andwithout any effect on the respiratory drive. • Remifentanil is a possible candidate and should be subjected to further research. • Also, comparative studies of different premedication strategies, preferably in a randomized controlledmanner, should be performed to determine the most effective and safe strategy for this purpose. EXPERIENCE AND COMPETENCE OF THE HEALTH CARE PROVIDER Endotracheal intubation is a difficult procedure with a relatively low first attempt success rate, even when performed by experienced personnel. However, success of intubation is highly influenced by the degree of experience of the health care provider. Health care providers with variable experience are successful in intubation at the first attempt in 44% to 73% of intubations. Pediatric residents have much lower first attempt success rates that are mainly between 20% and 45%. 3,4,6-9,95,96 In only one study, a success rate of 63% for pediatric residents was found. 5 Pooled data of 8 individual studies showed a first attempt success rate of 42% for pediatric residents, compared to 52% for fellows and 64% for attendings. 11 These data indicate that when being intubated by a pediatric resident the patient is more frequently exposed to multiple intubation attempts. Since an increasing number of attempts increases the risk of adverse events and severe hypoxic events and is also associatedwith intraventricular hemorrhage and neurodevelopmental impairment, intubation of vulnerable preterm infants by inexperienced airway providers should be prevented. The opportunities for pediatric residents to acquire and maintain proficiency in neonatal endotracheal intubation is a topic of serious concern. Evidence from anesthesia literature suggests that proficiency at intubation of adults takes over 40 procedures. 97-99 There is no clear evidence as to the amount of procedures needed to become proficient with neonatal intubation. Given the difficulty of the procedure due to the small size of mouth and airway and the anatomy of the larynx in neonates, it is not assumable that the amount of procedures needed to become proficient is lower compared to the adult population.