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Premedication for Difficult Neonatal Intubation

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Dear Colleagues,

I wanted to know what pre intubation drugs you are using and the rationale if you have a moment. I am also curious if you have a neonate with a difficult airway that had failed because it was vigorous would you paralyse with sedation and what would you use? Our PICU colleagues are pushing us to switching to Rocuronium more for consistency as they can reverse it with Sugammadex. I worry because of the duration for which Rocuronium takes away the babies drive as well as the fact the safety profile in neonates is not known. We currently use Atropine, Fentanyl and Suxamethonium.

Has any one used Sugammadex in neonates?

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Guest JoannieO

We also use Atropine, fentanyl and suxamethonium. The only time we don't premedicate for intubation is in an emergency situation where it is not possible to adequately ventilate the baby by bag and mask or Neopuff.

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Our standard drug protocol is for semi-elective and elective intubations in the NICU include atropine, fentanyl and suxamethonium. The atropine to negate the associated bradycardia that this babies experience with laryngoscope insertion, fentanyl because it has a faster onset of action (although chest wall rigidity has been seen if administered to rapidly - we give it as a slow push over 2 mins & suxamethonium because of it's rapid onset of action and very short T1/2). I have not had any experience with the use of rocuronium or sugammadex in the neonatal population.

I facilitate on the PaediatricBASIC course and the Paediatric Intensivists and Paediatric Anaesthetists are amazed that we still use suxamethonium in the neonatal population. There is definitely a trend in the "PICU world" seemingly towards the use of rocuronium. In saying that our "neonatal" (i.e. <28 days old) cardiac patients who go to PICU pre-op. are electively intubated with rocuronium I am told by our rotating registrars. I suppose this is a different scenario given that these patients will be maintained on a continuous infusion of muscle relaxation in the post-operative period. The literature on the subject seems a bit sparse - some interesting articles attached.........................

Rocuronium and sugammadex in a 3 day old neonate for draining an ovarian cyst - neuromuscular management and review of the literature.pdf

Sugammadex in the neonatal patient.pdf

Reversal of rocuronium-induced NMB by sugammadex in neonates.pdf

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There is not much evidence out there to support the use of rocuronium. Nevertheless rocuronium is supported by AAP, and as far as I understand their recommendation in this fairly  old paper, it is preferred to succinylcholine:

Premedication for Nonemergency Endotracheal Intubation in the Neonate

Praveen Kumar, Susan E. Denson, Thomas J. Mancuso and Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine
Pediatrics 2010;125;608-615; originally published online Feb 22, 2010;

DOI: 10.1542/peds.2009-286


We have used it for several years in our unit. It is comparable to succinylcholine in terms of onset of action, but of course the duration is longer. We still haven't had any adverse effects. I have no experience with sugammadex.


Chest rigidity with fentanyl is limited if slow infusion is used as pointed out in the post above




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We use Atropine, Fentanyl, thiopental and (sometimes) suxamethonium.

In my opinion we have a lot of stiff chest problems even if we give the fenanyl as a two minutes slow push.

In a difficult situation I would definitively go for propofol in combination with atropine and maybe fentanyl.

Ghanta S, Abdel-Latif ME, Lui K, et al. Propofol compared with the morphine, atropine, and suxamethonium regimen as induction agents for neonatal endotracheal intubation: a randomized, controlled trial. Pediatrics 2007;119:e1248–55. doi:10.1542/peds.2006-2708

The babies are really relaxed and well sedated, so intubation is quite easy (even in difficult situations).



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