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

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!

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 ?

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.

Thanks once again Stefan

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

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

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)

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)

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

hi this is very important topic .we have just 2to4 ventilators in our city in two different private hospitals .as most pediatricans work in public hospt and there arent any vents we dont attempt intubation because post intubation bagging cant be continued manualy for long,therefore intubation has now almost become out of practice. ido understand that spontaneous breathing can occur followed by extubation.my queston is that under these circumstances what is the role of nebulised surfactant and how is it used exactly in prematures followed by some fom of manual cpap.thanks

Nebulized surfactant is still experimental so as of today the only recommended route of administering surfactant is endotracheally. May be in a few years time we will have nebulized surfactant. IF there are no ventilators you can use INSURE and even if surfactant is not available just use plain CPAP and you will be able to save many preterm newborns

can u give me link or paper how can i give surfactant ,because i want to know ideal practise

thanks

can u give me link or paper how can i give surfactant ,because i want to know ideal practise

thanks

There are several papers describing the method, for example:

http://www.ncbi.nlm.nih.gov/pubmed/20971722

http://www.ncbi.nlm.nih.gov/pubmed/20180736

http://www.ncbi.nlm.nih.gov/pubmed/17476269

http://www.ncbi.nlm.nih.gov/pubmed/19117872

I personally think MIST and INSURE are really two versions of the same idea/practise, the major difference being the degree of sedation during the procedure.

Our protocol includes

1. premedication with atropine, fentanyl, penthotal and celocurin

2. intubation and administration of surfactant

3. await spontaneous breathing again and when it comes back (within minutes usually) extubation and back to cpap.

In the German speaking countries the technique described in these articles has found widspread use:

fn.bmj.com/content/early/2011/.../adc.2010.209098

www.thelancet.com/.../PIIS0140-6736(11)60986-0

www.ncbi.nlm.nih.gov/pubmed/17359406