Aims To assess the frequency of premedication use for neonatal unit intubations. To analyse medication use by condition of the baby and indication for intubation.
Methods Local guidelines for premedication use were reviewed. Data was collected contemporaneously in ten neonatal units (five ITU, four LNU, one SCBU) using a standardised proforma over an eight week period. Babies intubated on the unit were eligible for inclusion and were identified from weekly checks of the BadgerNet system and by reviewing the notes of ventilated babies. Data were collected on; weight, gestation, indication for intubation, choice and timing of medication, condition of the baby and documented reasons for not using premedication.
Results There were 307 intubations in total, 96 (31%) occurred on labour ward and were excluded. 212 neonatal unit intubations were analysed. Sixty-six (31%) of babies had no premedication for intubation. Of these; 30 (45%) were classified as being spontaneously breathing, 21 (31%) were apnoeic but could be mask ventilated, 6 (9%) were difficult to mask ventilate and 4 (6%) were apnoeic and bradycardic despite attempts to mask ventilate. An additional 12 (5%) babies had unsuccessful intubation attempts without premedication followed by successful intubation with premedication.
Forty percent of babies not receiving premedication had a documented reason for this decision in the notes. Reasons included; ‘No IV access’ (4), ‘Unable to cannulate’ (1) ‘Difficult to mask ventilate’ (3) and ‘in/out surfactant’ (6).
Units varied in their choice of medication. Morphine was used for analgesia in 55 intubations. Only three had a time gap of more than five minutes between morphine and muscle-relaxant. Given the delayed onset of action of morphine most these babies are unlikely to have received adequate analgesia during intubation.
Conclusions Previous research demonstrates that premedication blunts the adverse physiological responses to neonatal intubation and improves the chances of successful intubation. Providing analgesia and sedation for intubation should be considered humane care. Our data demonstrates that premedication is not used in all non-emergency intubations and could be used more widely. These results could be used to change current practice leading to quality improvement in patient care.
Acknowledgements The main contributors to the project are K Atkinson, H Mc Dermott, H Vawda, K Harvey, A Henderson, D Bogue, L Duthie, O Kowobari, R Yew, J Brindley, G Bhat, N Kottayankandy and A Ratcliffe. Consultant members of PRAM provided advice and supported the project, in particular A Ewer.
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