Ellen de Kort

178 Chapter 10 movements; 2 = movement on slight touch; 3 = movement in reaction to the firm stimulus; 4 = no movement. Scores 3 and 4 were believed to indicate a level of sedation that is sufficient to tolerate the act of laryngoscopy and placement of the endotracheal tube. Intubation was only proceeded when a score of 3 or 4 was reached. We implemented this IRS into clinical practice and performed a prospective observational study ( chapter 6 ) to evaluate the usefulness of this IRS in predicting the actual level of sedation. For this purpose, the positive predictive value of IRS 3 and 4 in predicting adequate sedation during the intubation procedure was determined. Sedation level was assessed by the intubation score of Viby-Mogensen and adequate sedation was defined as a good intubation score. The results of this study showed a positive predictive value of IRS 3 and 4 of 85%. In 15% of patients there was an inadequate level of sedation based on the intubation score, despite IRS 3 or 4. Univariate analysis revealed no patient factors influencing the ability of IRS 3 and 4 to predict an adequate level of sedation. Based on these results it can be concluded that the IRS is suitable for use in clinical practice but efforts should be made in expanding the score to further improve the positive predictive value. Also, the interrater variability in the firmness of the stimulus and the judgement of the motor reaction should be taken into account. PROPOFOL AS PREMEDICATION Although the administration of premedication in nonemergency endotracheal intubation is recommended for almost 20 years, there is still no consensus on which premedication strategy is most effective and safe. Propofol is one of the acceptable options and made its way into clinical practice in the last decade. Previously published studies on the use of propofol for endotracheal intubation in the neonatal population showed inconsistencies in the sedative effect of different propofol doses and concerns about its safety. In the last part of this thesis we aimed to find the optimal single propofol dose providing effective sedation without significant side effects in neonates of different gestational and postnatal ages. We performed a prospective multicenter dose-finding trial, that is described in chapter 7 . Included patients were stratified into eight different groups based on their gestational age and postnatal age. Dose-finding according to a step- up-step-down model based on sedative effects and side effects was performed in every of the eight groups. After an interim analysis of 91 included patients showed difficulty with inclusion in several of the age groups and a high risk of hypotension, the study was terminated. In two age groups the dose-finding procedure was finished but an optimal single propofol dose providing effective sedation without side effects