Ellen de Kort

83 Sedation assessment for neonatal intubation 5 In the majority of studies included in this review, quality of sedation is indeed the key factor to guide intubation. However, this is assessed in very diverse ways, often rather subjective or not further specified. Validated scoring systems are lacking, especially prior to elective intubation in the operating room. However, the literature describes three objective assessment tools used in the NICU: the easy-to-perform sedation score first described by Naulaers et al., the also easy-to-perform relaxation score first used by Smits et al., and the more extensive scoring system suggested by Thall et al. which is based on the N-PASS described by Hummel et al. 13,14,16,30 The purpose of validated objective scoring systems is to be able to predict effective sedation during the intubation procedure before actually starting the procedure, thereby preventing neonates from intubationwithout effective sedation. Validation of such scoring systems can be done by comparing the scoring systemwith the actual level of sedation during the intubation procedure in a larger group of patients. In neonatal intubation studies, the actual level of sedation during an intubation procedure is frequently assessed with the validated intubation score adopted fromViby-Mogensen et al. 31 In this intubation score, the items ease of laryngoscopy, position of the vocal cords, coughing, jaw relaxation, and movement of the extremities are all judged on a 4-point scale. A score of 2 or less on each item reflects effective sedation. Although both using the Viby-Mogensen intubation score to qualify level of sedation during the intubation procedure, the reports of Smits et al. and De Kort et al. do not provide enough information to draw any conclusions about the accurateness of the sedation and relaxation scores. In the sedation score, the absence of a motor reaction or only a slight motor reaction to a firm stimulus is presumed to indicate the neonate will tolerate the insertion of the endotracheal tube into the supraglottic airway. However, in this assumption, the used stimulus should be stronger than the act of inserting an endotracheal tube. The question rises if the act of inserting an endotracheal tube, mainly via the nasal route, requires a stronger stimulus than heel rubbing. For example, by anesthesiologists, the much firmer stimulus of pinching the trapezius muscle is frequently used before inserting a supraglottic airway. Validation of that stimulus in a clinical study has not been reported. In summary, although both sedation and relaxation scores seem potentially useful scores in the neonatal population, validation of these scores is mandatory before further use. The scoring system suggested by Thall et al. concerns a comprehensive and precise scoring system, which is likely to adequately reflect the level of sedation. Also, different definitions can be used in case of different needs of sedation level according to its purpose. However, to the best of our knowledge, clinical trials using this scoring system