Ellen de Kort

43 Remifentanil for INSURE in preterm newborns 3 INTRODUCTION To prevent distress and adverse physiological responses, traumatic damage and failed procedures, neonatal intubation should always be performed with the use of premedication. 1-3 One of the most frequent reasons to intubate neonates is to administer surfactant for respiratory distress syndrome. During the INSURE (intubation, surfactant, extubation) procedure, patients are only briefly intubated for the administration of surfactant and extubated immediately thereafter. To facilitate this rapid extubation, the premedication used should have a rapid onset and very short duration of action. A recent review on the use of premedication before intubation during the INSURE procedure showed no conclusive evidence on the optimal premedication but stated that remifentanil was probably the best candidate because of its unique pharmacological profile. 4 Remifentanil has an extremely brief action, high predictability, rapid onset and offset of action, and immediate recovery of the clinical effect after interruption of the administration. 5 The results of previous studies using remifentanil as single agent were also encouraging. 6-8 We performed an observational prospective study to evaluate the effects and side effects of remifentanil bolus infusion as premedication before the INSURE procedure and report here the results of implementing remifentanil into clinical practice. METHODS Study population This prospective study was performed at the level III neonatal intensive care unit of the Erasmus MC Sophia Children’s Hospital in Rotterdam, the Netherlands. Before January 2013, surfactant was always administered during a period of mechanical ventilation and propofol was used as premedication before intubation. In January 2013 the standard of care was changed to performing the INSURE procedure for the administration of surfactant in all infants with a gestational age ≥27 weeks and birth weight ≥750 g. As premedication for the INSURE procedure we started to use remifentanil. Remifentanil was administered intravenously as a fast bolus and followed by an intravenous saline flush in 30 s. After administration, the level of sedation was assessed with a standardized sedation score, performed by rubbing the sole of the patient’s foot and judging the motor reaction to that stimulus (1 = spontaneous movement; 2 = movement on slight touch; 3 = movement in reaction to firm stimulus; 4 = no movement). 9 In case of inadequate sedation (score 1 or 2), another dose of remifentanil was administered according to the protocol. If sedation was adequate (score 3 or 4), the procedure was