Ellen de Kort

23 Sedation for the INSURE procedure 2 INTRODUCTION Endotracheal intubation is a frequently performed procedure in the neonatal intensive care unit (NICU). 1 It is a stressful procedure associatedwith pain and adverse physiological responses when the neonate is awake. Adverse effects include hypoxia, bradycardia, systemic hypertension, and increased intracranial pressure with a potential risk of intraventricular hemorrhage, especially in preterm infants. 2-6 Intubationwithout the use of premedication may lengthen the procedure, require a greater number of attempts, 4-6 and cause traumatic damage to the face, eyes, tongue, gums, and glottic structures. 6,7 With this in mind, clinicians have started to routinely administer premedication. 2-4,8-11 However, there is still no consensus about the best drugs for neonatal intubations. 12,13 The most frequent reason for intubation in preterm neonates is surfactant replacement therapy for respiratory distress syndrome (RDS). Incidence of RDS is 92% in 24-25 weeks, 88% in 26-27 weeks, 76% in 28-29 weeks, and 57% in 30-31 weeks. Starting early with nasal continuous positive airway pressure (nCPAP) can reduce the need for surfactant replacement therapy in RDS by 50%. 14 Historically, surfactant was administered via a tracheal tube during mechanical ventilation. As mechanical ventilation may damage the pulmonary system and cause bronchopulmonary dysplasia (BPD), new techniques have been introduced to shorten the duration of mechanical ventilation as much as possible. In the INSURE (INtubation, SURfactant administration, immediate Extubation) method, infants are endotracheally intubated only for surfactant administration and are extubated immediately thereafter and put on nCPAP again. A Cochrane review in 2008 showed that the INSURE method significantly decreased the need for mechanical ventilation (relative risk (RR) 0.72, 95% confidence interval (CI) 0.59– 0.87), the incidence of BPD (RR 0.68, 95% CI 0.57–0.79) and the incidence of air leak syndromes (RR 0.52, 95% CI 0.28– 0.96). 15 Intubation in the context of the INSURE procedure still requires the administration of premedication. However, rapid recovery of the respiratory drive is essential for the success of the INSURE procedure. As extubation should take place within several minutes after surfactant administration, the sedative agent used must have a very short duration of action. There is no consensus about what agent is most suitable as premedication for INSURE procedures. The goal of this paper is to determine the most appropriate sedative for neonatal intubation during the INSURE procedure by reviewing the literature.