Ellen de Kort

77 Sedation assessment for neonatal intubation 5 the intubating clinician’s observation of insufficient sedation led to the administration of more premedication to achieve an adequate level of sedation and/or relaxation. 7,13,14,17-19,21,22 In the remaining four studies, this was not mentioned at all. 15,16,20,23 2597 records identified through database searching Embase n = 1199; Medline n = 799; Web of Science n = 321; Cochrane n = 78; Google Scolar n = 200 1653 records screenend for relevance 945 of 2597 records removed because of duplicates 1 record added identified by hand searching 75 full text articles assessed for eligibility 1577 of 1653 records excluded because of non-relevance 20 articles included in the systematic review 55 of 75 full text articles excluded: no relevant outcome n = 50; not available n = 4; language restriction n = 1 Figure 1. Flowchart of included and excluded studies In 7 of all 20 included studies, intubation was started after a certain period of time had elapsed after the administration of premedication. 5,6,24-28 The methods section of these studies neither made clear if level of sedation also played a role, nor if all patients were adequately sedated upon start of the intubation procedure. In one study, preoxygenation was the leading parameter to start with intubation. 29 Only 4 of the 20 studies used an objective scoring system to assess the level of sedation before proceedingwith intubation. These objective scoring systems are outlined in Table 3. The first scoring system is a sedation score used in two different reports. Smits et al. used this score in their dose-finding study for propofol in newborns and De Kort et al. used the score in a study on the use of remifentanil in preterm infants undergoing the INSURE procedure. 13,14 The score is adopted from the study of Naulaers et al. into the effectiveness of methohexital as premedication for elective intubation. 15 The level of sedation is assessed by the motor response to a firm stimulus by rubbing of the feet (1 = spontaneous movement, 2 = moves on slight touch, 3 = moves on stimulus, 4 = no movement). In both studies, sedation was presumed to be effective with scores 3 and 4, upon which intubation was started.