Ellen de Kort

98 Chapter 6 respiratory insufficiency was the reason in 45 (52%) and 4 (27%) patients, respectively. Three patients with good Viby-Mogensen intubation scores were intubated for elective reasons versus none of the patients with inacceptable Viby-Mogensen intubation scores. Differences in reasons for intubation between both groups were not statistically significant (p = 0.116). DISCUSSION Premedication should be used for intubation in neonates whenever possible to minimize adverse physiological events, to reduce duration and number of attempts, to prevent traumatic injury to the airway, and to provide comfort. Accordingly, the intubation procedure should only be startedwhen the given premedication has achieved a sufficient degree of sedation. However, validated objective scoring systems to assess the readiness for intubation are lacking. 19 This study aimed to evaluate the suitability of an IRS to assess if a newborn is ready for intubation after administration of premedication. We showed that this IRS can predict good quality of intubation in 85% of patients. In the literature, no previous studies can be found that investigated the readiness for intubation. Arecent systematic reviewshows only three potentially suitable scoring systems, all of themnot validated. 19 One of these scores is the sedation score described byNaulaers et al. that we used to develop our IRS. 20 Another score to assess the level of sedation prior to intubation in neonates is the “good sedation state” fromThall et al. 23 This score is based on the Neonatal Pain, Agitation and Sedation Scale developed byHummel et al. 24 and consists of 5 variables: crying/irritability, behavior state, facial expression, extremity tone, and vital parameters. Each item is scored on a 5-point scale from –2, corresponding to highest sedation, to +2, corresponding to highest infant discomfort. According to Thall et al., good sedation for endotracheal intubation is defined as a total score between –7 and –3. 23 To the best of our knowledge, further evaluation of this score has not been performed. Though this score might reflect the degree of sedation very accurately, it is an extensive and time consuming score that makes it less suitable to perform in a semi-acute situation. We have therefore chosen to further evaluate the sedation score of Naulaers et al. 20 Adequate prediction of the quality of intubation in 85% of patients also means that in 15% of patients the IRS did not adequately predict the level of sedation during the intubation procedure. This might be explained by the fact that heel rubbing is a weaker stimulus than the introduction of the endotracheal tube into the nose or laryngoscopy. In this case, a stronger stimulus that better reflects the pain and stress of laryngoscopy and/or introducing the endotracheal tube into the nose should be used. However, introducing