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Medication for Intubation - How do you do it

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… and how comfortable are you with your choice?


So, we all know, that there has been and still is a wide variety of combinations for premedication for intubating a neonate - even more difficult when dealing with preterms.

As far as I know, most current recommendations favour using an opioid, a muscle relaxants and mostly atropine.

I “grew up” using thiopental and fentanyl +- Rocuronium and often times a second dose of fentanyl was needed until placing the tube (nasoteacheal) was tolerated. 

So for me, using Fentanyl and Rocuronium without an hypnoticum right away, makes me somewhat uncomfortable fearing too little medication effect and too much awareness.


So, what is your combination and how do you feel using it? I’m curious ….

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I use IV low dose Midazolam and low dose  IV Fentanyl ....or Low dose Lorazepam IV and low dose IV Vecuronium. Either of combination works well. I do not use any of these medications if baby is already depressed and not active for age because those babies do not resist much if at all since their muscles are already not having little to no tone. 

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That depends on the infants condition.

In case of a stable infant that needs intubation for surgery or anything like this, I use a small dose Propofol (1-2 mg/kg) followed by Fentanyl (2-3 µg/kg) and Rocuronium in the higher dose (1 mg/kg). Sufentanil 0,5 µg/kg instead of Fentanyl is an option when early extubation is needed.

In case of a sick infant (sepsis,.....) I rather use Ketamin 0,5 - 1 mg/kg alone or no meds because the neonate may not be that vigourus and the above mentioned medication may even depress the baby more than I want.

I never use Atropine.

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Started with fentanyl, atropine and rocuronium. Over the years I am uncomfortable with fentanyl. I have  seen some cases of wooden chests and people who couldn‘t  handle it. 
Dropped atropine over the years too, because of unfavourable energy balance. 

Today Ketamine and midazolam and rocuronium.

I am still struggle with the benzodiazepine.  Maybe we should use ketamine alone?

What do you think?

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Before 2007 the primary medication in our department was atropine, midazolam, morfine and rocuronium. Our main population are (extreme) prematures needing short time ventilation and we have no surgery. Problem was that is was not possible to get patients (premature intubated for RDS) fast from the ventilator. To optimize this and support early extubation we switched to combination atropine, fentanyl (5/kg), rocuronium (0,3) if necessary, based on literature, and used this for about 10 years. Not everyone was happy with this combination, sometimes Tx rigidity occured needing extra relaxation and so one of my collegues started a research project on this. 

Today we use primarely propofol (1-6 mg/kg) titrating by effect (intubation readyness score) and combine this with rocuronium (0,3) if needed. Atropine is not standard medication and depends on attendend performing procedure, is used by some collegues more than others ;-). For patients with (potential) circulation problem (PPHN, sepsis, …) we use ketamine S 0,5 - 1 mg/kg alone. An opioid (fentanyl) we only add if we expect the patient staying on ventilator for longer period.     

Atropine, Fentanyl, rocuronium we still have as secondary combination - and is used especially by (older)  colleagues still not trusting safety of propofol in our population  🙂

I think the strongest improvement in our department was focussing on effect of medication (intubation redyness score) and working on standardisation of medication and timing effect and dosing as we don’t have a lot of “crash intubations”.   

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