133 Thiopental/Suxamethonium/Remifentanil Premedication is Superior to Morphine for Semi Urgent Intubation in Preterm Infants -A Randomized Blinded Intervention Study

Abstract

Background: No evidence-based guidelines for intubation premedication are available for newborn infants. Our aim was to investigate, in a blinded RCT, whether semi-urgent intubation is more successful with rapid sequence intubation (RSI) using analgo-sedation and relaxation than with morphine. Patients and Methods: Preterm infants (n = 39) needing semi-urgent intubation, stratified for gestational and postnatal age, were randomized after parental consent. They were allocated to receive either glycopyrron 5 mikrog/kg, thiopental 2-3 mg/kg (2 mg/kg < 1000 g), suxamethonium 2 mg/ kg and remifentanil 1 microg/kg (RSI) or atropine 0.01 mg/ kg and morphine 0.3 mg/kg before nasal intubation. The primary outcome measure was "good intubation conditions" (i.e. Viby Mogensen intubation score <10, all subitems <2). Secondary outcomes were duration of procedure, number of attempts, physiological and biochemical parameters, pain scoring (ALPS 0 and EDIN) and amplitude-integrated EEG (aEEG) scoring2. The duration of the procedure included ventilation and suction. Results: Analysis of 34 infants demonstrated superior intubation conditions, median (interquartile range) intubation score 5 (5-6) vs 12 (10-13.5), (P < .001), shorter duration, 45 seconds (35-154) vs 97 (49-365), (P = 0.031) and less need for additional drugs (P = 0.036) in the RSI group. Compared to RSI the morphine group had prolonged heart rate decrease (3.5-fold AUC, P = 0.037) and mean arterial blood pressure (MABP) increase (median change 21% vs -2%, P < 0.007, 4-fold AUC, P = 0.039) during intubation, and a progressive MABP decrease (P = 0.001) concomitant with neurophysiological depression (P < 0.001) for 6 h afterwards. Plasma cortisol and stress/pain scores were similar. Conclusion: RSI provides optimal intubation conditions, shorter procedure duration and less need for additional drugs than morphine, which should be avoided because of circulatory and neurophysiological depression during and after the intubation.