Ellen de Kort

176 Chapter 10 in a higher proportion of patients but also to a high incidence of chest wall rigidity. The study was prematurely ended after the inclusion of 14 patients. The high incidence of chest wall rigidity could have been caused by the fast infusion rate of remifentanil that we used in our study. A fast infusion rate can cause higher peak levels with increased side effects as a consequence. In conclusion, remifentanil as a fast bolus over 30 seconds is not appropriate as premedication for the INSURE procedure. During LISA, mechanical ventilation is completely avoided and surfactant is administered through a thin catheter that is placed between the vocal cords by laryngoscopy in patients who are spontaneously breathing on nCPAP. Because of the possible depressant effects of premedication on the respiratory drive, LISA is most often performed without the use of premedication, despite the previously gained knowledge on the harmful effects of awake laryngoscopy. In a prospective observational study described in chapter 4 , we evaluated the effects of performing a LISA procedure without sedative premedication on the success rate, technical quality of the procedure and vital parameters in preterm newborns. The success rate of the first attempt was 52% and in 41% of procedures the technical quality was inadequate. There was also a strong correlation between success and technical quality. These results could point to patient discomfort and intolerance. Analysis of vital parameters in a subpopulation of study patients in whom vital parameter data were available, showed that heart rate was significantly higher in the first 30 minutes after start of the LISA procedure compared to baseline. Bradycardia <80/min did not occur. These results are most probably attributable to the administration of atropine, which was standard procedure. At 1 and 2 minutes after the start of the LISA procedure oxygen saturation was significantly lower compared to the oxygen saturation before start of the LISA procedure. Besides this, oxygen desaturations <80% in the first 30 minutes occurred in 54% of patients. These desaturations probably do not only reflect an effect of awake laryngoscopy, but also the administration of surfactant. From the results of this study it can be concluded that performing LISA procedures without sedative premedication is accompanied by a low success rate and frequent inadequate technical quality. The use of sedative premedication could improve success and technical quality, and possibly also decrease the incidence of oxygen desaturations to some extent. The use of atropine seems to have a preventive effect on bradycardia and should, therefore, be considered.