The Importance of a Protocol for Premedication Prior to Intubation
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Purpose: Endotracheal intubation is an invasive procedure that is completed frequently in the neonatal population. Premedication protocols are recommended but are infrequently utilized in neonatal intensive care units across the United States. The purpose of this quality improvement project was to evaluate the effectiveness of a premedication protocol prior to intubation of the preterm infant. Methods: An evaluation was completed to examine the effects of a premedication protocol on physiological tolerance and improved conditions for intubation. The population for this evaluation were infants less than 28 days of life admitted to the NICU with a gestational age of 24-36 weeks. Excluded were infants with congenital airway malformations as well as term infants. Informed consent was obtained from parents and the ‘Bedside Monitoring: Elective Intubation Tolerance’ form was utilized as the evaluative tool for this study. Results: There was no improvement in pain scores or number of intubation attempts when neonates were given fentanyl and atropine alone prior to endotracheal intubation. The average number of attempts was 1.9 for all infants, with and without fentanyl administration. One dose of fentanyl was given to 90% of infants, and no infants received a second dose, and only one received a sedative, such as midazolam. There was more than one attempt to achieve intubation in 60% of infants. There was no statistical significance in pain scores of infants who received premedication. Conclusions: The utilization of premedication protocols prior to non-emergent intubation of the preterm infant has been a recommendation for many years by the AAP. Clinical studies have positively demonstrated improved tolerance of the procedure, decreases in intubation attempts, and improved outcomes post-procedure with use of a premedication protocol that includes an analgesic, sedative and vagolytic. The sample was small in this project, with twenty-one participants over a five-month span, which may have affected the outcome. Also, all providers performing intubation were experienced with intubation without medication, and accustomed to the procedure. There was a reluctance to provide sedation in addition to analgesia, despite previous studies proving its importance. Further evaluation with a larger population, complete premedication and more varied skill level of providers is needed to confirm these findings.