Premedication for nonemergent neonatal intubations: a randomized, controlled trial comparing atropine and fentanyl to atropine, fentanyl, and mivacurium.
OBJECTIVE
The purpose of this work was to investigate whether using a muscle relaxant would improve intubation conditions in infants, thereby decreasing the incidence and duration of hypoxia and time and number of attempts needed to successfully complete the intubation procedure.


METHODS
This was a prospective, randomized, controlled, 2-center trial. Infants requiring nonemergent intubation were randomly assigned to receive atropine and fentanyl or atropine, fentanyl, and mivacurium before intubation. Incidence and duration of hypoxia were determined at oxygen saturation thresholds of < or = 85%, < or = 75%, < or = 60%, and < or = 40%. Videotape was reviewed to determine the time and number of intubation attempts and duration of action of mivacurium.


RESULTS
Analysis of 41 infants showed that incidence of oxygen saturation < or = 60% of any duration was significantly less in the mivacurium group (55% vs 24%). The incidence of saturation level of any duration < or = 85%, 75%, and 40%; cumulative time > or = 30 seconds; and time below the thresholds were not significantly different. Total procedure time (472 vs 144 seconds) and total laryngoscope time (148 vs 61 seconds) were shorter in the mivacurium group. Successful intubation was achieved in < or = 2 attempts significantly more often in the mivacurium group (35% vs 71%).


CONCLUSIONS
Premedication with atropine, fentanyl, and mivacurium compared with atropine and fentanyl without a muscle relaxant decreases the time and number of attempts needed to successfully intubate while significantly reducing the incidence of severe desaturation. Premedication including a short-acting muscle relaxant should be considered for all nonemergent intubations in the NICU.
Roberts
Kari D
KD
Division of Neonatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA. rober694@umn.edu
Leone
Tina A
TA
Edwards
William H
WH
Rich
Wade D
WD
Finer
Neil N
NN
D000759:Adjuvants, Anesthesia / Q000627:therapeutic use*; D001285:Atropine / Q000627:therapeutic use*; D001794:Blood Pressure; D004359:Drug Therapy, Combination; D005260:Female; D005283:Fentanyl / Q000627:therapeutic use*; D006339:Heart Rate; D006801:Humans; D000860:Hypoxia / Q000209:etiology / Q000517:prevention & control; D007231:Infant, Newborn; D007440:Intubation / Q000009:adverse effects / Q000379:methods*; D007546:Isoquinolines / Q000627:therapeutic use*; D008297:Male; D000077590:Mivacurium; D003473:Neuromuscular Nondepolarizing Agents / Q000627:therapeutic use*; D010100:Oxygen / Q000097:blood; D011446:Prospective Studies; D016896:Treatment Outcome
D000759:Adjuvants, Anesthesia; D007546:Isoquinolines; D003473:Neuromuscular Nondepolarizing Agents; D000077590:Mivacurium; D001285:Atropine; D010100:Oxygen; D005283:Fentanyl