Ellen de Kort

177 Summary 10 MEASUREMENT OF THE EFFECT OF PREMEDICATION It is well known that laryngoscopy and endotracheal intubation in awake neonates are often associatedwith adverse physiological events, which can beminimized or prevented by the use of premedication. The purpose of administering premedication, therefore, is to provide a level of sedation sufficient to perform the procedure of intubationwithout serious adverse events and in the least amount of time. The intubation procedure, therefore, should only be started after this level of sedation is achieved. There is, however, no uniform definition of sufficient sedation and there is much variability in the determination of the level of sedation in clinical practice. In the second part of this thesis we aimed to standardize the intubation procedure by developing an objective scoring system to determine the level of sedation after the administration of premedication. The first step was to provide insight into the availability of objective and validated scoring systems to assess the level of sedation in the neonatal population. For this purpose, we performed a systematic review of the literature, as described in chapter 5 . This systematic review showed that there are no validated scoring systems available. A search into studies describing common practice on how level of sedation is determined, revealed 20 studies to be included. In eight of the included studies (40%), the decision to proceed with the intubation after the administration of premedication was not based on the level of sedation. In these studies, intubation was started after a period of time presumed to be enough for drug effect had elapsed, or after the patient was pre-oxygenated. In another eight studies (40%) the decision to proceed with intubation was based on the sedation level, but this was determined subjectively or it was unclear how thiswas determined. In only four studies (20%) sedation level was evaluated objectively by certain scores. From these studies, a total of three objective sedation assessment tools could be retrieved: the sedation score, based on themotor response after applying a firmstimulus assessed on a 4-point scale; the relaxation score, based on themuscle tone of the extremities also assessed on a 4-point scale; and the sedative state, based on the Neonatal Pain Agitation and Sedation (N-PASS) scale in which 5 items are all assessed on a 5-point scale. The sedation and relaxation scores are both very easyandquickly to perform, the sedative state is amore extensive and time consuming score that is probably less suitable for a situation as acute as neonatal intubation. In conclusion, this systematic review revealed three promising sedation assessment tools, all needing further validation before they can be implemented into clinical practice. As a second step in this part of the thesis, we developed an Intubation Readiness Score (IRS) that was based on the sedative score that came forward from the systematic review. It consisted of the application of a firm stimulus, rubbing the heel of the patient's foot, and judging the motor reaction to that stimulus on a 4-point scale: 1 = spontaneous