Ellen de Kort

63 Less Invasive Surfactant Administration without sedation 4 In summary, comparison of our findings in awake LISA with studies using sedative premedication prior to LISA shows that success rates and effects on vital parameters are comparable. This should not encourage neonatologists to keep on performing LISA in awake patients. There is enough evidence on the harmful effects of awake laryngoscopy during endotracheal intubation and there is no reason to believe these effects would be different in the context of a LISA procedure. LISA, therefore, should always be performed with the use of sedative premedication. This premedication, however, should have the least effect on the respiratory drive and should not hamper LISA success. More research is obviously needed to determine the best premedication strategy. Success of intubation attempts is not only determined by the use of sedative premedication. Level of experience of the operator is also an important determinator of success. 36 In our study, we found a significant correlation between the success of LISA and the level of experience of the operator. Of all LISA procedures in which the first attempt was successful, it was performed by a neonatologist in 73%, compared with 33% of the procedures in which the first attempt failed. For endotracheal intubation it is known that the use of premedication improves the success rates of inexperienced operators. 37,38 It is likely that this is also applicable for LISA. Irrespective of the use of premedication, operator level of experience and number of attempts needed are important factors increasing the odds for endotracheal intubation related adverse events. 36,39,40 Although there are no studies evaluating the occurrence of LISA related adverse events, it is presumable that the incidence of adverse events during LISA is also influenced by these factors. The operator for LISA should, therefore, be carefully chosen. Lack of data on success and technical quality because of missing registration forms led to the exclusion of almost 25% of patients that underwent LISA in our study, which could have led to selection bias. The excluded population, however, had comparable baseline characteristics compared with the included patients. The included patients are a good reflection of the total population of preterm infants undergoing LISA and, therefore, our results have good generalizability. Our study has several limitations. First limitation is the use of atropine prior to LISA. One of the goals of our study was to determine the effects of awake LISA on vital parameters. We found a significant increase in heart rate at all time points after start of LISA, but this is most probably due to the administration of atropine, rather than a reflection of patient stress and discomfort. Nevertheless, we encourage the use of atropine prior to LISA, since it prevents the occurrence of bradycardia and its related risk for hypoxia.