INSURE

[kpsanghvi]

Namaste Netters

Do you have different or modified INSURE protocols different from what is published by Bohlin et al 2007 or by Dani et al 2004

The questions I would like to ask are

What are the indications?

Do you use any pre-medication?

Fraction of volume of surfactant delivered?

Post medications for reversal?

How long do you bag after administration of each fraction?

How long do you bag after administering the complete dose before reinstituting nCPAP

How do you control pressures during administration

[Stefan Johansson]

As Bohlin (Kajsa Bohlin) is my colleague we use the protocol as described in her paper from 2007 (http://www.ncbi.nlm.nih.gov/pubmed/17476269)

Our indications are gestational age>27+0 weeks, RDS documented by x-ray and an a/A-ratio (despite CPAP 4-5 cm) of <0.22.

We premed the babies with atropin+fentanyl+penthotal (and some use celocurin for muscle relaxation too) before intubation and administration of surfactant (we use Curosurf)

Surfactant is instilled as a slow injection through a sideport of the ET-tube, during ongoing gentle ventilation (NeoPuff), pressures depending on the baby's condition.

We don't have a fixed time/nb of breaths after admin of surfactant, but continue ventilation until the baby is breathing spontaneously again and we can extubate (typically a few minutes)

Would be interesting to hear more views/protocols!

[kpsanghvi]

Thanks Stefan for the information. A few more queries -

Have you had any cases of respiratory depression after using fentanyl and pentothal and if yes have do you use naloxone to reverse it or put the infant on the ventilator? Also what doses of Fentanyl and Pentothal do you use?

Have you ever tried using only Fentanyl?

With the advent of MIST ( Dargaville 2011) do you think there will be any need for sedation analgesia before administering surfactant ?

[Stefan Johansson]

There is some respiratory depression but hardly happens that the baby needs mechanical ventilation after the procedure (has happened once, as I recall it, MV was used for 1 hour)

So, we don't use Naloxone generally. The spontaneous breathing comes back shortly after the instillation of surfactant and we then just extubate the baby.

Fentanyl dose: 2mikrog/kg

Penthotal dose: 2 (-5) millig/kg

MIST... personally I think that the laryngoscopy is the a stressful part of the procedure, and therefore I would not feel good about not using any analgesia/sedation, even if surfactant would be admin with a small feeding tube/without intubation. But, I guess others have different opionions about this.

[kpsanghvi]

Thanks once again Stefan

[jorabim]

I think INSURE is probably could be performed without sedation and analgesia in delivery room. But for the late surfactant therapy sedation and analgesia is obligate. We use fentanyl dose: 3-4mikrog/kg, relanium 0.05mg/kg and atropine. have experience of using naloxone after respiratory depression (respiratory recovery in 1 minute) and the following extubation

[JACK]

Are the drugs that we use for sedation / analgesia in neonates really safe ? Do these drugs themselves have any deleterious effects (long term neurodevelopmental) ?

[jorabim]

to be honest, i have no idea if this drugs influence on the long term conditions.. but for the the short term it is proved to be reliable (preventing of ventricular hemmorage for ex)

[kpsanghvi]

to be honest, i have no idea if this drugs influence on the long term conditions.. but for the the short term it is proved to be reliable (preventing of ventricular hemmorage for ex)

[kpsanghvi]

Would you call prophylactic surfactant given in delivery room with CPAP as INSURE. My understanding of the term INSURE is that it is used only in established RDS