Do you use premedication for LISA/ MIST procedure? What combination do you use? We have started our LISA procedures successfully, but a lot of concerns from our faculty that we should be using premedication as we do for intubations. Any advice much appreciated.

Do you use premedication for LISA/ MIST procedure? What combination do you use? We have started our LISA procedures successfully, but a lot of concerns from our faculty that we should be using premedication as we do for intubations. Any advice much appreciated.

We started off with 28-34w and for those on neonatal unit only (plan to include delivery room once unit confidence builds up). For this category we use sucrose + swaddle only. However we’ve been facing an occasional vigorous baby, who we have had to revert to premedication and ventilation. We need to find a middle ground for these babies. Maybe LMA/ fentanyl/ ramifentanyl?


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From Tw!

 

 

We've been doing LISA/MIST for a few years now, but there is still no clear guideline in our hospital concerning premedication. Almost every attending and fellow uses some sort of narcotic, though everybody uses different medication, and some use no premedication at all (most of the time). I'm wondering, does anybody use Propofol for LISA/MIST currently? If so, what is your experience with it? Which dosage do you use?

We are doing MIST/LISA from 24 weeks onwards. We use sucrose en facilitated tucking, wich works fine in most of the cases, and, if necessary (rarely), atropine. We do not use any other premedication except caffeine, of course. But it remains an issue. If a baby is too vigoruous we switch to INSURE with propofol sedation. 

The colleagues in Leiden use propofol, 0,5-1 mg/kg I think. They published a paper in 2018: https://pubmed.ncbi.nlm.nih.gov/30068669/

We have started LISA just last year in Umeå, Sweden. We use premedication schedule with caffeine, atropin and esketamin (Ketanest). Works well. Our nurse staff have got many problems to accept laryngoscopy without any premedication.

 

We've been practising LISA from 2007 on in the dpt i was til 2016 an the meds were Coffein Atropin Propofol, later we saw it worked well without caffein- unfotunately i'm not up to date concerning neuro(developm.) issues with using Propofol in preemies, if ist's still safe i would use it again, worked well titrating 1mg/kg Up to 2 or 3 

This just came on my radar, a review of premedication for a LISA procedure.

https://fn.bmj.com/content/early/2024/10/10/archdischild-2024-326947.info

It all comes down to very little (no!) guidance...

Quote

...optimal premedication or non-pharmacological management for LISA are currently unknown. Ongoing studies will provide further information to guide clinical practice. In the interim, the effectiveness of analgesia of different approaches should be balanced against the likelihood of short and longer term adverse effects. The published data are presented here, but as evidence to inform practice are incomplete, considerable variation in practice is likely to persist.

 

There are guidelines published, here is one from France:

https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2022.1075184/full 

Would love to hear more. Propofol is very commonly used in the PICU, but less so with our neonates. What would be the main reason to use it or not?

We just reviewed our experience with Ketamine, used in 100% of our LISA since we introduced the protocol. Occasional apnea requiring PPV, but most tolerate it very well.

16 hours ago, kbarrington said:

We just reviewed our experience with Ketamine, used in 100% of our LISA since we introduced the protocol. Occasional apnea requiring PPV, but most tolerate it very well.

What dosage do you use? 0.25 or 0.5 mg/kg? 

17 hours ago, kbarrington said:

We just reviewed our experience with Ketamine, used in 100% of our LISA since we introduced the protocol. Occasional apnea requiring PPV, but most tolerate it very well.

IMHO ketamine seems like a very good choice. We use fentanyl and my experience is not the best, it usually works but sometimes we do see thorax rigidity or insufficient analgesia.

Do you also premed with atropine? Have you done some kind of systematic discomfort scoring etc, ie are you happy with the analgesia?

We give atropine as a routine, then 1 mg/kg of ketamine, a few babies have a supplemental 0.5 mg/kg dose. It is so difficult to score pain during an invasive procedure with several people in the room and at least 2 at the head of the baby. I'm reasonably happy with the analgesia given that limitation.