Ellen de Kort

44 Chapter 3 continued. INSURE procedures were always performed by neonatologists and clinical fellows experienced in neonatal intubations. As soon as the respiratory drive recovered after surfactant administration, the patient was extubated and commenced with nasal continuous positive airway pressure. Use of remifentanil Based on the results of the study by Avino et al. 7 and our inexperience with remifentanil, we decided to start with a lowdose of 1 μg/kg. When sedationwas inadequate, this dose could be repeated no more than twice (period 1). If sedation was still inadequate after three doses, the patient received propofol (1 mg/kg) and surfactant was administered in the conventional way. Because sedation was inadequate in four of the first five patients, the starting dose of remifentanil was increased to 2 μg/kg. When sedation was inadequate, another dose of remifentanil was given and each subsequent dose was increased with 1 μg/kg relative to the previous dose with a maximum dose of 5 μg/kg (period 2). If sedation was still insufficient, propofol (1 mg/kg) was given and surfactant was administered in the conventional way. Outcome measures The primary outcome measure was the quality of sedation, defined as the combination of an adequate sedation score, adequate intubation conditions and the absence of side effects. Intubation conditions were classified with a validated intubation score by rating laryngoscopy, vocal cords, coughing, jaw relaxation and limb movements (Table 1). 10 Intubation conditions were good when the total score was ≤10 with a score on each item ≤2. Hypotension and chest wall rigidity were defined as side effects. Hypotension was defined as a mean blood pressure lower than gestational age and chest wall rigiditywas defined as the inability to inflate with normal pressures. Secondary outcomes were the number of remifentanil doses, maximum remifentanil dose, need for propofol to achieve adequate sedation and intubation attempts. Table 1. Intubation score Item Score 1 Score 2 Score 3 Score 4 Laryngoscopy Easy Fair Difficult Impossible Vocal cords Open Moving Closing Closed Coughing None Slight Moderate Severe Jaw relaxation Complete Slight Stiff Rigid Limb movements None Slight Moderate Severe