Background and aims Premedication for neonatal intubation should provide fast and adequate sedation with a minimum of side-effects. Aim of this study was to evaluate effect and safety of remifentanil as premedication during INSURE in preterm neonates.

Methods Remifentanil was prospectively studied using increasing dosages (Table 1). Outcome measures were adequate sedation, defined as adequate sedation score, good intubation conditions and absence of side-effects, and duration of respiratory depression. To exclude degradation or dilution errors as explanation for observed variability in response, pharmaceutical analysis was performed after simulated preparation.

Results The study was terminated after inclusion of 14 patients. A dose of 1 ug/kg did not provide adequate sedation in 80% of patients. Higher dosages also resulted in inadequate sedation in 89% of patients and were frequently associated with chest rigidity (36%). Duration of respiratory depression was reported in 6 patients, with a median of 18 min (mean 16.5 min, range 5 seconds to 30 min). Pharmaceutical analysis showed a concentration of the active substance of 80 to 112% of the expected concentration, indicating adequate stability and preparation.

Conclusion Remifentanil intravenously over 30 seconds frequently not provides adequate sedation and has a high risk of chest wall rigidity in preterm neonates. Also, duration of respiratory depression is quite long for use during INSURE.