Ellen de Kort

25 Sedation for the INSURE procedure 2 used. Thus, ten additional publications were included, next to both studies ofWelzing et al. The following sedativeswere evaluated: remifentanil, propofol, fentanyl, morphine, and a combination of morphine and pentobarbital. Characteristics of the studies regarding the INSURE procedure are summarized in Table 1 and detailed information about the effects and side effects of the premedication that was used is provided in Table 2. Remifentanil. In the study of Welzing et al. a total of 21 preterm infants received 10 μg/kg atropine and 2 μg/kg remifentanil prior to intubation. Fifteen patients (71%) were intubated at the first attempt and six patients (29%) at the second attempt. First failed attempts were ascribed to inexperience of residents in training and not to insufficient sedation. Intubation conditions were excellent in 14 patients (67%) and good in 7 patients (33%). No serious side effects occurred. CPAP could be started at a mean of 10.9 minutes (range 1–30 minutes) after surfactant administration, and mean time to extubation was 42.4 minutes (range 1–330 minutes). 16 Propofol. A pilot study ofWelzing et al. evaluated the effect of propofol as premedication before intubation during the INSURE procedure. This pilot was supposed to continue for one year but was stopped prematurely because of significant problems with arterial hypotension. Thirteen preterm infants underwent the INSURE procedure and received 10 μg/kg atropine and 1 mg/kg propofol. Intubation was successful at the first attempt in nine patients (69%) and at the second attempt in four patients (31%). Failed first attempts were ascribed to inexperience of residents in training. Intubation conditionswere excellent in five, good in six, and inadequate in two patients, respectively. Propofol gave only a short period of respiratory depression and nCPAP could be started at a mean of 25 minutes (2 to 120 minutes) after surfactant administration. One patient needed reintubation after INSURE because of inadequate respiratory drive. In 5 of 13 patients significant arterial hypotension was observed. 17 Morphine. Five of the 10 additionally included publications concerned morphine monotherapy in a dosage of 100 or 200 μg/kg. 18-22 The use of naloxone was optional in most studies, 18,19,21 standard practice in one study, 22 and not mentioned in one study. 20 None of these five studies provided details on intubation conditions and number of attempts for successful intubation. The studies of Van den Berg et al. and Flor-de-Lima et al. did not address time to restoration of spontaneous breathing and INSURE failure because of insufficient breathing or apnea. 18,22 In the study of Cherif et al., all patients were extubated within 6.3 ± 1.7 minutes (range 5–12 minutes) after surfactant administration. However, INSURE failed in 35 patients (32.1%) but reasons for this failure and the time frame between extubation and INSURE failurewere not mentioned. 20 Verder et al. did not mention time to extubation but did mention INSURE failure in 15 patients (43%): 2 patients