Premedication for neonatal intubation: which medications are recommended and why.

Three decades ago, few scientists and health care providers believed infants and young children were able to localize and/or perceive painful stimuli.1 This assumption that infants and children did not feel pain led to infants undergoing surgical and other painful procedures (e.g., lumbar puncture, endotracheal intubation) without any medication for pain and anxiety.2 This assumption has now been proven to be untrue. Today, infants routinely receive analgesia and sedation for surgical procedures in the operating room, but the extent to which infants routinely receive medication for other painful procedures varies. A common, painful procedure for critically ill neonates is endotracheal intubation;3 however the administration of medications prior to intubation varies substantially. In the most recent survey from 2006 in the United States,4 only 44% of neonatology fellowship program directors reported routine use of analgesia and/or sedation before intubation. A survey of neonatal intensive care units (NICU) in the United Kingdom in 2009 reported that 90% of the units routinely administered premedication prior to elective intubations.5 Intubation can cause traumatic injury to the airway,6 as well as lead to physiologic instability during the procedure.7, 8 Despite the possible negative impact of intubation, the procedure is often necessary and many times life saving. Critically ill neonates are often intubated nonemergently in the NICU due to prematurity, need for prolonged ventilation, endotracheal tube change, or an unstable airway.9 In 2010, the American Academy of Pediatrics (AAP)10 recommended premedication be used for all intubations in neonates, except in the case of emergent intubation during resuscitation. The goal of premedication is to eliminate pain, discomfort, traumatic injury to the airway, and physiologic instability (e.g., bradycardia, hypotension/hypertension, decreased oxygen saturation) associated with endotracheal intubation procedure.10 To implement this recommendation in the NICU, written policies are needed to guide health care providers. However, the previous surveys found that the number of NICUs with written policies on premedication ranged from ‘few’ to 75% of units.4, 5 It is ideal when clinical pharmacists, neonatologists, and neonatal nurse practitioners work together in the design of premedication policies.11 However, since nurses often administer medications and act as advocates for their vulnerable patient; nurses also can also lead the way in collaborative policy development based on empirical evidence. Written policies when available and followed have the potential to reduce medication errors and improve the quality of care within the NICU. Therefore, the purpose of this integrated review is to explore current research evidence on medication(s) utilized for nonemergent intubation in preterm and term neonates. PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and the Cochrane database were searched to obtain English language publications from 1990 to November 2011. The year 1990 was chosen because this is when the health care literature began conducting clinical trials on patients receiving procedural sedation and analgesia.2 The inclusion criteria were clinical studies using medication(s) prior to neonatal (≤ 28 days of life) intubation. Studies were excluded if the average age of the participants was greater than 28 days of life, did not include humans, medications were no longer available in the United States, single case reports of infants with abnormal facies or rare diseases, and trials that focused on anesthetic gases due to lack of feasibility in the NICU. Sixteen studies met the inclusion criteria and included 436 neonates. The findings were organized by the classification of the medications administered (vagolytic agents, analgesia, sedation, and neuromuscular blocking agents) with advantages and disadvantages explained and current AAP recommendations and rationale provided. See Table 1 for a summary of medications utilized for premedication in nonemergent intubation. Table 1 Medications for Premedication for Nonemergent Intubation