Ellen de Kort

84 Chapter 5 are lacking. Therefore, any conclusion about its accuracy and usability is not possible and validation is needed before future use. Even if validated, the scoring system must prove its suitability in daily practice. In neonatal intubation, fast performance of the procedure is mandatory, especially when fast acting agents are used. The extensiveness of the score could possibly make it time consuming and therefore less suitable. Despite the lack of validated objective scoring systems, several reports do have shown that premedication before neonatal intubation has become standard practice in the majority of neonatal units. 10,11,32-38 There is, however, much debate about which premedication or premedication regimen is best. Studies evaluating certain premedication strategies are mainly focusing on using one dosing strategy for the entire neonatal population. However, pharmacodynamics and pharmacokinetics are influenced by factors such as gestational age, postnatal age and morbidity. For example, Smits et al. found that neonates of different gestational ages needed different doses of propofol for adequate sedation. 13 Most important in our opinion is that the used premedication achieves effective sedation. It should also have a quick recovery to allow for fast extubation, and have no significant side effects. The search for the most suitable premedication strategy should be directed towards personalized medicine and focus on administering just enough premedication to achieve adequate sedation in the individual patient. For this purpose, a scoring system that adequately indicates the level of sedation is mandatory. Thework of field and the techniques used differ between pediatric anesthesiologists and neonatologists. For example, they have different drug choices, pursue different levels of anesthesia (deep vs superficial) and require different duration of sedation (hours vs minutes). However, the goals of administering premedication during induction in the operating room and before intubation in the NICU are comparable and in both situations the level of sedation should be objectively assessed before continuing the procedure. With his in mind, neonatologists and anesthesiologists can possibly share valuable knowledge in this area of the field. With the availability of a validated scoring system that can make a distinction between different levels of sedation, it should then be possible to use a single scoring system for both settings. Limitation of this review is that we used the description of the intubation procedure in the methods section to answer the questions of our secondary objective. Because describing the entire procedure from administration of premedication to intubation was not the primary goal of the included studies, it is possible that these descriptions were not complete and that more scoring systems or other parameters were used in practice.