Transition to Routine Premedication for Nonemergent Intubations in a Level IV Neonatal Intensive Care UnitFunding None.
26 April 2017
28 August 2017
11 October 2017 (eFirst)
Objective This study aims to test whether implementing a guideline for nonemergent intubation improves the rate of premedication for nonemergent intubations in an academic level IV neonatal intensive care unit (NICU). We further sought to test the hypothesis that neonates who receive premedication for a nonemergent intubation have decreased pain scores at the time of intubation, fewer intubation attempts, and no associated adverse events.
Study Design This was a prospective observational study with ongoing audit and feedback as well as statistical process control analysis. Data collection began on October 1, 2014. Clinical guideline implementation began in October 2015. A percent “P”-chart spanning seven-quarters was constructed with statistical process control analysis plotting premedication rates over time. Student's t-tests or Wilcoxon rank-sum tests were used for secondary outcomes.
Results The mean number of nonemergent intubations given premedications increased from 34 to 82%. The mean pain score was lower when premedications were given: 0.34 (95% confidence interval [CI]: 0.10–0.58) versus 2.8 (95% CI: 1.9–3.6) (p < 0.001). The number of intubation attempts did not differ with premedications.
Conclusion Adopting a guideline with supporting educational initiatives to standardize premedication before nonemergent intubations increased this practice. This regimen lowered clinical pain scores with no difference in the number of intubation attempts.
Rachel Fleishman, MD: Conceptualized and designed the study, monitored, and supervised all data collection from the St. Christopher's Hospital for Children, performed the initial analyses, drafted the initial article, and approved the final article as submitted. Roschanak Mossabeb, MD: Monitored and supervised all data collection from the Temple University Hospital (ultimately not included in the final article) and revised and approved the final article as submitted. Ogechukwu Menkiti, MD: Led the clinical team with guideline implementation and facilitated data collection at the St. Christopher's Hospital for Children, critically reviewed and edited the article, and approved the final article as submitted. Megan Young, PharmD, BCPS: Helped develop the clinical practice guideline, facilitated data collection at the St. Christopher's Hospital for Children, critically reviewed and edited the article, and approved the final article as submitted. Vidhy Bains, Pharm D, BCPS: Helped develop the clinical practice guideline, facilitated data collection at St. Christopher's Hospital for Children, critically reviewed and edited the article, and approved the final article as submitted. David Cooperberg, MD: Provided mentorship and oversight for study design, performed the statistical process control analysis, critically reviewed and edited the article, and approved the final article as submitted.
- 1 Kumar P, Denson SE, Mancuso TJ. ; Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine. Premedication for nonemergency endotracheal intubation in the neonate. Pediatrics 2010; 125 (03) 608-615
- 2 Taddio A, Stevens B, Craig K. , et al. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med 1997; 336 (17) 1197-1201
- 3 Grunau RE, Haley DW, Whitfield MF, Weinberg J, Yu W, Thiessen P. Altered basal cortisol levels at 3, 6, 8 and 18 months in infants born at extremely low gestational age. J Pediatr 2007; 150 (02) 151-156
- 4 Brummelte S, Chau CM, Cepeda IL. , et al. Cortisol levels in former preterm children at school age are predicted by neonatal procedural pain-related stress. Psychoneuroendocrinology 2015; 51: 151-163
- 5 Ranger M, Zwicker JG, Chau CM. , et al. Neonatal pain and infection relate to smaller cerebellum in very preterm children at school age. J Pediatr 2015; 167 (02) 292-8.e1
- 6 Carbajal R, Rousset A, Danan C. , et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA 2008; 300 (01) 60-70
- 7 Durrmeyer X, Daoud P, Decobert F. , et al. Premedication for neonatal endotracheal intubation: results from the epidemiology of procedural pain in neonates study. Pediatr Crit Care Med 2013; 14 (04) e169-e175
- 8 Ng E, Taddio A, Ohlsson A. Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit. Cochrane Database Syst Rev 2017; 1: CD002052
- 9 Attardi DM, Paul DA, Tuttle DJ, Greenspan JS. Premedication for intubation in neonates. Arch Dis Child Fetal Neonatal Ed 2000; 83 (02) F161
- 10 Sarkar S, Schumacher RE, Baumgart S, Donn SM. Are newborns receiving premedication before elective intubation?. J Perinatol 2006; 26 (05) 286-289
- 11 Muniraman HK, Yaari J, Hand I. Premedication use before nonemergent intubation in the newborn infant. Am J Perinatol 2015; 32 (09) 821-824
- 12 Hancock S, Newell S, Brierley J, Berry A. Premedication for neonatal intubation: current practice in Australia and the United Kingdom. Arch Dis Child Fetal Neonatal Ed 2000; 83 (01) F77
- 13 Mosalli R, Shaiba L, Alfaleh K, Paes B. Premedication for neonatal intubation: Current practice in Saudi Arabia. Saudi J Anaesth 2012; 6 (04) 385-392
- 14 Wheeler B, Broadbent R, Reith D. Premedication for neonatal intubation in Australia and New Zealand: a survey of current practice. J Paediatr Child Health 2012; 48 (11) 997-1000
- 15 Whyte S, Birrell G, Wyllie J. Premedication before intubation in UK neonatal units. Arch Dis Child Fetal Neonatal Ed 2000; 82 (01) F38-F41
- 16 Raban MS, Joolay Y, Horn AR, Harrison MC. Newborns should be receiving premedication before elective intubation. S Afr Med J 2014; 104 (12) 846-849
- 17 Carbajal R, Eble B, Anand KJ. Premedication for tracheal intubation in neonates: confusion or controversy?. Semin Perinatol 2007; 31 (05) 309-317
- 18 Porter FL, Wolf CM, Gold J, Lotsoff D, Miller JP. Pain and pain management in newborn infants: a survey of physicians and nurses. Pediatrics 1997; 100 (04) 626-632
- 19 de Kort EH, Reiss IK, Simons SH. Sedation of newborn infants for the INSURE procedure, are we sure?. BioMed Res Int 2013; 2013: 892974
- 20 Barrington K. Premedication for endotracheal intubation in the newborn infant. Paediatr Child Health 2011; 16 (03) 159-171
- 21 Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw 1993; 12 (06) 59-66
- 22 Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine. Prevention and management of procedural pain in the neonate: An update. Pediatrics 2016; 137 (02) e20154271
- 23 Provost LP, Sandra KM. The Health Care Data Guide: Learning from Data for Improvement. San Francisco, CA: Jossey-Bass Publishers; 2011
- 24 Le CN, Garey DM, Leone TA, Goodmar JK, Rich W, Finer NN. Impact of premedication on neonatal intubations by pediatric and neonatal trainees. J Perinatol 2014; 34 (06) 458-460
- 25 Hatch LD, Grubb PH, Lea AS. , et al. Interventions to improve patient safety during intubation in the neonatal intensive care unitit. Pediatrics 2016; 138 (04) e20160069
- 26 Avino D, Zhang WH, De Villé A, Johansson AB. Remifentanil versus morphine-midazolam premedication on the quality of endotracheal intubation in neonates: a noninferiority randomized trial. J Pediatr 2014; 164 (05) 1032-1037
- 27 Durrmeyer X, Dahan S, Delorme P. , et al. Assessment of atropine-sufentanil-atracurium anaesthesia for endotracheal intubation: an observational study in very premature infants. BMC Pediatr 2014; 14: 120
- 28 Walter-Nicolet E, Zanichelli C, Coquery S, Cimerman P. Implementation of a specific premedication protocol for tracheal intubation in the delivery room. Practice in two level-III hospitals [in French]. Arch Pediatr 2014; 21 (09) 961-967
- 29 Akuma AO, Jordan S. Pain management in neonates: a survey of nurses and doctors. J Adv Nurs 2012; 68 (06) 1288-1301
- 30 Rohan AJ. The utility of pain scores obtained during ‘regular reassessment process’ in premature infants in the NICU. J Perinatol 2014; 34 (07) 532-537
- 31 Maxwell LG, Malavolta CP, Fraga MV. Assessment of pain in the neonate. Clin Perinatol 2013; 40 (03) 457-469
- 32 Grunau RE, Whitfield MF, Petrie-Thomas J. , et al. Neonatal pain, parenting stress and interaction, in relation to cognitive and motor development at 8 and 18 months in preterm infants. Pain 2009; 143 (1-2): 138-146