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Stefan Johansson

Fentanyl as premed for intubation - what is your experience (really...)?

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Hi all!

I was trained to use morphine as premed before (semi-planned) intubation but our protocol and practise has changed to fentanyl as analgesic drug (in addition to atropin, pento and +/- celocurin)

What is your experience with stiffening of the chest and laryngospasm?

If you use fentanyl, what is your dose and over how many minutes do you inject it?

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Hi Stefan,

when I started training we used morphine as well, but we have changed to fentanyl as well. We combine it with vecuronium. We do not give any additional sedative or atropine.

I do not recall any incidences of laryngospasm from fentanyl, but stiffening of the chest does occur maybe in 10% of cases.

Our prefered dose is 5mcg/kg - and we only rarely have to give an additional dose. We inject it over half a minute. What we do see is hypotension sometimes a few hours after intubation that we believe is also a side-effect from giving fentanyl.

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Interesting to hear, especially the short injection time.

Do you use the same dose regardless of gestational age (23-43 weekers).

My thoughts about our (sporadic) problems are that we use a too low dose (usually around 3 mikrog/kg) and give it too slowly (over a few minutes). The general belief in our unit is that lower dose, and a more "gentle" administration would reduce the risk of stiff chest/laryngospasm.

But, I start to think that babies gets too little analgesia, that the reaction we see is due to discomfort.

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Hi Stefan

 

We have used fentanyl for many years now, at I think 4 - 5 mcg/kg.  We dilute 100mcg of fentanyl with 6 mls of sterile water and draw up the dose from this solution, then give slowly over 5 minutes.  We also give the flush slowly over 5 minutes.  We rarely have problems with chest stiffness, and when we do, it seems that it is because it is given too quickly.  We also use atropine but our muscle relaxant of choice is suxamethonium - fast acting and short duration.

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Hi Stefan,

 

We use Fentanyl at a lower dose (0.5-2mcg/kg) given over min of 2 minutes combined w/ Midazolam 0.1mg/kg also given over min of 2 minutes.

We have seen instances of chest wall rigidity, so we go low & slow.

Alternately we use Morphine 0.1 mg/kg.

Neofax is our med reference.

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Has anyone used ketamine. I have never used it but the thought keeps on coming to my mind and would it be a better alternative

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Hi lmedina81,

We have used remifentanil in other indications in neonates with mixed results. Thorax rigidity seems to be a bigger issue compared with fentanyl.

 

Compare:

http://www.ncbi.nlm.nih.gov/pubmed/20231228

 

furthermore, at the last EAPS conference in Barcelona there was a Dutch group reporting their experience with remifentanil (I dont recall where in the NL) and they reported high incidence (up to 50%) of thorax rigidity as well.

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We use fentanyl 2mcg/kg over 3 minutes, followed by a flush for three minutes. We also give atropine and vecuronium. Prior to the vecuronium, if patient does not appear adequately sedated/comfortable, we have the option to give a second fentanyl dose. We only use the second dose about 20% of the time. No chest wall rigidity so far (have been using this regimen for almost 2 years).

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We trried this hundreds of time together with midazolam and always be ready with naloxone as antidote

The good thing is that there is one article about giving naloxone to minimize reintubation in patients given fentanyl as premediction before INSURE

111071

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hi stefan,

1-2mcg/kg/dose given over 1-2 minutes (higher starting dose in non-opiate naive pt) repeat if needed + 0.1mg/kd midazolam (not used in preemies) + 1-1.2mg/kg Rocuronium (or Vec depending on what is in stock) [neuromuscular block being optional and requiring a fellow or attending at bedside to give].  I can recall only one incidence of chest wall rigidity having use this combination over a hundred times (with the caveat that over time I have come to almost universally give Roc/Vec).

Regarding Ketamine, I have never intubated with it, but have certainly used it for conscious sedation.  My concern would be what neurodevelopment effects Ketamine has on a preemie.

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Dear Stefan

 

We are doing  PROSPECTIVE STUDY ON premade intubation drugs (Project NIK) and have collected data on 168 interventions with the combination of Fentanyl Atropine Suxamethonium. More details here https://www.mproveacademy.com/quality-mprovement/toolkits

 

Register and click on Toolkit 1 elective neonatal intubation

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