Ellen de Kort

9 General introduction 1 GENERAL INTRODUCTION In the early 1980’s the first reports appeared in the literature describing the harmful effects of performing endotracheal intubation in neonates without the use of premedication. In an observational trial in 10 preterm infants, Marshall et al. examined the physiological changes that were associatedwith awake endotracheal intubation. The authors observed a decrease in heart rate and transcutaneous oxygen tension, and an increase in systolic blood pressure during laryngoscopy and placement of the endotracheal tube. 1 Shortly after this, Kelly et al. were the first to perform a randomized controlled trial in which awake intubation in neonates was compared to intubation with the use of premedication. They reported a significantly lower increase in intracranial pressure and less decrease in heart rate in infants who were treated with pancuronium and atropine before intubation, compared to infants who received only atropine or no premedication. 2 After these reports, a number of studies evaluated the effects of different premedication strategies compared to awake intubation. Results of these reports showed that awake intubation resulted in a greater increase in intracranial pressure, 2-6 elevated systemic blood pressure, 5-8 tachycardia, 3,7 bradycardia 2,9 and hypoxemia 10 compared to the administration of premedication prior to endotracheal intubation. Awake intubation also resulted in a longer duration to complete successful intubation and a higher number of intubation attempts. 7-11 In 2001, this knowledge about the harmful effects of awake intubation resulted in a consensus statement on the prevention and management of pain in the newborn. It was stated that endotracheal intubation should only be performed without analgesia or sedation for resuscitation in the delivery room or in emergency situations without the availability of an intravenous access. 12 In all other situations, premedication should be used during neonatal intubation. At that time, the routine use of premedication prior to nonemergency intubation was only around 40% in several countries. 13-15 After the harmful effects of awake intubation became apparent, the routine use of premedication for nonemergency endotracheal intubation became subject of extensive research all around the world. In the last 20 years, a tremendous increase in the routine use of premedication up to around 90% was seen. 16-19 Despite the increased use of premedication, there was extensive variability in the drugs that were used as premedication and their dosages. 13,16,17,19-21 An ideal premedication strategy for endotracheal intubation in newborns should eliminate pain and discomfort, minimize the physiological abnormalities that can accompany laryngoscopy and intubation, prevent trauma to the airway and provide circumstances to perform a successful procedure as quickly as possible. Besides this,