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nashwa

Premedication before INSURE

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Any one practice to give premedication before INSURE techniques or no need

 

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We talk about it. I want to get there, but one not so great experience makes me hesitant. If we are doing INSURE in our delivery room, I don't think it is practical enough and leans more to emergent in those cases. But if we are admitted in our unit, then I think it is the best. I'm convinced its better for babies getting intubated in general, but not consistent in my practice yet. FYI, we don't routinely use muscle relaxant and our standard is atropine and fentanyl. 

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I have never practiced with a group that did INSURE, but I've often wondered about premedication, especially after the study from Albany with an astonishingly high failure rate when using morphine as the premedication.  Helpfully, that same group now provides data on use of remifentanyl instead: https://www.ncbi.nlm.nih.gov/m/pubmed/29789465/

Personally, the biggest change for me once we go to INSURE (assuming we don't just skip to MIST/LISA) is that I've routinely muscle relaxed for intubation for a number of years.

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In our unite we routinely give premedication to all elective intubation, but I wondered about given medication before INSURE, is it needed. Because I think it prolong duration on mechanical ventilation. We are not able to wean baby quickly. We give usually atropine, fentanyl and suxammethonium

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Though there is a protocol in place to premedicate with fentanyl for elective intubation and INSURE in the unit, not really sure how to go about it if the baby does not have a iv line in place and requires surfactant but not iv fluids. Most of our babies would be started on full feeds if there are no contraindications(aggressive enteral nutrition). 

Should a iv cannula be inserted for administering analgesia before INSURE!? and then removed. 

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11 hours ago, Akash Sharma said:

Though there is a protocol in place to premedicate with fentanyl for elective intubation and INSURE in the unit, not really sure how to go about it if the baby does not have a iv line in place and requires surfactant but not iv fluids. Most of our babies would be started on full feeds if there are no contraindications(aggressive enteral nutrition). 

Should a iv cannula be inserted for administering analgesia before INSURE!? and then removed. 

I have no idea what the cost is, but intranasal fentanyl could be an option.  I've only ever used it in a palliative setting, but all out babies who would be insure candidates are getting IV placed for fluids.  Even with aggressive enteral nutrition we used a few days of fluid.

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We practise pre-med for INSURE (atropin+fentanyl+pento and some use celo) - my experience is good with regards to cardiovasc and respiratory stability.

But as @Nathan Sundgren says, we don't premed if we need to do INSURE right after delivery.

Around here, the INSURE procedure also means pre-med, while LISA/MIST is the term used when surfactant is given without pre-med. Originally, when LISA/MIST was first done and studied by Angela Kribs and co-workers  (https://www.ncbi.nlm.nih.gov/pubmed/17359406https://www.ncbi.nlm.nih.gov/pubmed/18298776https://www.ncbi.nlm.nih.gov/pubmed/18298776) I think their idea was to minimize any drug-related impact on the breathing drive. So they tested with no drugs and it worked well for them. I know many share this experience, that surfactant can be instilled without any pre-med.

I personally feel concerned about the laryngoscopy as such, I believe atropine and analgesics would still have a place also in LISA/MIST. And for younger colleagues less experienced with laryngoscopy and intubation, I think the procedure may also be more uncomfortable for infants not given analgesia. 

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We usually don't use any sedation for LISA.

If the baby is big and vigorous, I prepare some remyfentanyl and use it only if needed.

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We've been using remyfentanil previous to LISA, but we've experienced some undesirable side effects (apnea) needing naloxone to revert.  Previously we used small doses of propofol, but it has been abandoned due to the concerns about its neurotoxicity...This was the last topic of discussion in the last session of Catalan Neonatal Studies  Group...a lot of variability in practice, fears, lack of evidence and safety data... What about bolus of dexmedetomidine?  Seems safe but still few studies..

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It is evident that intubation generates a feeling of discomfort in the child who undergoes this procedure. For the method IN.SUR.E. We started using fentanyl, but the results were not good. Currently, we are not using any medication for that procedure, although we are aware that the procedure is annoying for the baby.

 

Fernando Agama C.

Unidad de Neonatología

Hospital Enrique Garcés

Quito-Ecuador

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It is evident that intubation generates a feeling of discomfort in the child who undergoes this procedure. For the method IN.SUR.E. We started using fentanyl, but the results were not good. Currently, we are not using any medication for that procedure, although we are aware that the procedure is annoying for the baby.
 
Fernando Agama C.
Unidad de Neonatología
Hospital Enrique Garcés
Quito-Ecuador
You use fentanyl only???

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We use standard Premade intubation drugs for all elective intubations but nothing for Lisa 
Which premedication you give???

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Fentanyl Atropine Suxamethonium
What is dose of fentanyl??

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Can I know average duration on ventilator after INSURE?? Does it affect by given suxamethonium??

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Please note we dont use intubation drugs for either LISA or INSURE.  Suxamethonium is very short acting but we only use our preintubation drugs where we plan not to extubate immediately. I would not routinely sedate and paralyse a baby I was planning to insure.

 

I simply dont buy the argument that the use of Fentanyl at 0.5 microgram per kg has any analgesic effect for the patient. It might do for the nurses looking after the baby. If you want to use analgesia during intubation best use it properly to have an analgesic effect.

 

Alok

 

 

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On 6/16/2019 at 12:59 AM, Nathan Sundgren said:

We talk about it. I want to get there, but one not so great experience makes me hesitant. If we are doing INSURE in our delivery room, I don't think it is practical enough and leans more to emergent in those cases. But if we are admitted in our unit, then I think it is the best. I'm convinced its better for babies getting intubated in general, but not consistent in my practice yet. FYI, we don't routinely use muscle relaxant and our standard is atropine and fentanyl. 

Thank you for your comment .. but can u tell me please why to use atropine ?

 

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On 6/30/2019 at 4:31 PM, spartacus007 said:

I simply dont buy the argument that the use of Fentanyl at 0.5 microgram per kg has any analgesic effect for the patient. It might do for the nurses looking after the baby. If you want to use analgesia during intubation best use it properly to have an analgesic effect.

I was unaware anyone was arguing that 0.5mcg/kg/dose reliably provided any clinically meaningful effect in the context of direct laryngoscopy.  There are, however, doses of fentanyl between 0.5mcg/kg and 5mcg/kg which almost certainly offer some analgesic relief and (at least as importantly) provide a side effect of sedation which improve intubating conditions while not so suppressing respiratory drive that extubation becomes impossible.

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Thanks all for your comment, but still I want to know if you plan to do INSURE technique, are you giving premedication or no, and what is average duration on mechanical ventilator or you extubate immediately regardless the gestational age ??

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