title: Predictors for an unsuccessful INtubation-SURfactant-Extubation procedure: a cohort study.
abstract: BACKGROUND
  The INtubation-SURfactant-Extubation (INSURE) is a procedure that is increasingly being used to treat the respiratory distress syndrome in preterm infants. The objective of this study was to identify predictors for an unsuccessful INSURE procedure.
  
  
  METHODS
  The neonates included were less than 32 weeks' gestation, treated with surfactant in the neonatal intensive care unit, and born 1998-2010. INSURE was defined as surfactant administration during intubation for less than 2 hours without the need for mechanical ventilation. INSURE success was defined as no re-intubation within 72 hours after INSURE, and INSURE failure was defined as re-intubation within 72 hours after INSURE. An unsuccessful INSURE procedure was either INSURE failure or mechanical ventilation for more than 24 hours immediately after surfactant administration. All predictors were defined a priori and were present before surfactant administration. Multivariate logistic regression was performed.
  
  
  RESULTS
  In total, 322 neonates were included: 31% (n = 100) had INSURE success, 10% (n = 33) had INSURE failure, 49% (n = 158) needed mechanical ventilation for more than 24 hours, and the remaining 10% (n = 31) needed mechanical ventilation for less than 24 hours. Predictors for INSURE failure were low gestational age and hemoglobin below 8.5 mmol/l. Predictors for mechanical ventilation for more than 24 hours were low gestational age, Apgar at 5 minutes below 7, oxygen need above 50%, CO2 pressure above 7 kPa (~53 mmHg), pH below 7.3, lactate above 2.5 mmol/l, need for inotropes, and surfactant administration shortly after birth, whereas preeclampsia reduced the risk.
  
  
  CONCLUSIONS
  We identified specific predictors associated with an unsuccessful INSURE procedure. Keeping high-risk neonates with one or several predictors intubated and treated with mechanical ventilation after surfactant may prevent a re-intubation procedure.
authors.forename: Nis
authors.initials: N
authors.lastname: Brix
authors.forename: Anna
authors.initials: A
authors.lastname: Sellmer
authors.forename: Morten Søndergaard
authors.initials: MS
authors.lastname: Jensen
authors.forename: Linda Vad
authors.initials: LV
authors.lastname: Pedersen
authors.affiliation: Perinatal Epidemiology Research Unit, Aarhus University Hospital, Brendstrupgaardsvej 100, Aarhus N 8200, Denmark. tbh@dadlnet.dk.
authors.forename: Tine Brink
authors.initials: TB
authors.lastname: Henriksen
mesh_terms: D060666:Airway Extubation; D001034:Apgar Score; D002245:Carbon Dioxide / Q000097:blood; D002316:Cardiotonic Agents / Q000627:therapeutic use; D015331:Cohort Studies; D005260:Female; D005865:Gestational Age; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007231:Infant, Newborn; D007234:Infant, Premature; D007363:Intensive Care Units, Neonatal; D007440:Intubation; D019344:Lactic Acid / Q000097:blood; D008297:Male; D015999:Multivariate Analysis; D010102:Oxygen Inhalation Therapy / Q000706:statistics & numerical data; D011663:Pulmonary Surfactants / Q000627:therapeutic use*; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012127:Respiratory Distress Syndrome, Newborn / Q000628:therapy*; D017211:Treatment Failure
chemical_list: D002316:Cardiotonic Agents; D006454:Hemoglobins; D011663:Pulmonary Surfactants; D002245:Carbon Dioxide; D019344:Lactic Acid