NICU Premedication for Non-Emergent Endotracheal Intubation Algorithm

Purpose: The purpose of this algorithm is to provide guidance for the use of evidence-based premedications for endotracheal intubation in the Vanderbilt NICU.  This algorithm should not replace clinical judgment.

 

Resources: This algorithm has been developed using currently available literature as well as input from multiple specialties including Neonatology, Anesthesia and Pediatric Critical Care. The basis for many of the recommendations below comes from the 2010 AAP Clinical Report “Premedication for Nonemergency Endotracheal Intubation in the Neonate” which is linked below:

http://pediatrics.aappublications.org/content/125/3/608.full.pdf+html

 

Setting: This algorithm pertains to all non-emergent endotracheal intubations performed in the NICU. Non-emergent endotracheal intubations are defined as those intubations where the infant is able to be effectively bag-mask ventilated prior to the intubation attempt and time is available for medication administration.

 

Monitoring: All infants undergoing endotracheal intubation in the NICU should have cardiopulmonary monitoring including continuous telemetry, pulse oximetry and blood pressure monitoring. In addition, audible pulse oximetry should be used during the intubation attempt. Baseline vital signs including blood pressure should be recorded (if patient stability allows) prior to intubation. After successful placement of an endotracheal tube, vital signs including blood pressure should be documented again.

 

Access: Intravenous (IV) access should be obtained in all infants prior to endotracheal intubation. If the infant is unstable, unable to be bagged or having significant cardiorespiratory compromise necessitating emergent intubation, IV access can be deferred. If an IV is unable to be placed, premedication can be given according to the recommendations below.

 

Caveats:

·       These recommendations do not replace clinical judgment and will not fit all clinical scenarios.

·       Personnel skilled in endotracheal intubation should be present at every procedure.

·       All equipment necessary for successful placement of an artificial airway should be present at bedside prior to intubation. This includes laryngeal mask airways, bag-mask with proper fitting mask, oral airways and all equipment needed for intubation.

·       Use of a sedative/hypnotic (such as Versed/midazolam) or muscle relaxant (Rocuronium, Vecuronium) without use of an analgesic agent for intubation is prohibited.

·       A muscle relaxant should only be used after verifying the ability to mask ventilate and in the presence of an attending physician. Neuromuscular blockade should not be routinely used in infants with upper airway anomaly or craniofacial anomalies unless approved by attending neonatologist or ENT attending.

·       Muscle relaxants should not be used for intubations for in and out surfactant.

 

Recommendations for Premedications:

 

Preterm Infants (<34 weeks postmenstrual age):

·       Atropine 0.02 mg/kg IV (no minimum dose)

·       Fentanyl 1-4 mcg/kg IV given over 3-5 minutes

·       Rocuronium 1mg/kg IV (should be considered)

o   Vecuronium 0.1mg/kg IV can be used if Rocuronium is not available but is discouraged given longer time to onset and longer half-life.

·       Versed or other benzodiazepines should not be used in this population due to higher incidence of hypotension, bradycardia and oxygen desaturation.

 

Late preterm and term infants (34 weeks or greater PMA) without congenital heart disease

·       Fentanyl 2-4 mcg/kg IV given over 3-5 minutes

·       Versed 0.05-0.1mg/kg IV given over 3-5 minutes (can be considered)

·       Atropine 0.02 mg/kg IV (no minimum dose) (can be considered)

·       Rocuronium 1mg/kg IV (should be used unless there are contraindications)

o   Vecuronium 0.1mg/kg IV can be used if Rocuronium is not available but is discouraged given longer time to onset and longer half-life.

 

Infants with ductal-dependent congenital heart disease or poor cardiac function

·       Fentanyl 2-4 mcg/kg IV given over 3-5 minutes

·       Rocuronium 1mg/kg IV (should be used unless there are contraindications).

o   Vecuronium 0.1mg/kg IV can be used if Rocuronium is not available but is discouraged given longer time to onset and longer half-life.

·       Versed or other drugs that may affect systemic vascular resistance should be avoided.

 

Infants with craniofacial anomalies, signs of upper airway obstruction or known/suspected difficult airways

·       Fentanyl 1-4mcg/kg IV given over 3-5 minutes.

·       Contact ENT or Anesthesia prior to procedure

o   Anesthesia Airway Phone- 615-516-XXXX

o   ENT Resident pager- 615-831-XXXX

·       Neuromuscular blockers should not be routinely used in this population due to possibility of upper airway obstruction and inability to effectively bag-mask ventilate. Discuss with attending prior to use.

 

Infants without central or peripheral access

·       Fentanyl 2-4 mcg/kg IM or

·       Fentanyl 1-2 mcg/kg intranasally

·       No clinical trials or observational studies evaluating the safety or efficacy of IM or intranasal medications for pain control in neonates prior to endotracheal intubation have been published. A small study which evaluated the use of intranasal midazolam for intubation in the delivery room was published with mixed results. Given this lack of data, every attempt to secure vascular access prior to non-emergent endotracheal intubation should be made.

 

Reversal Agents:

 

Fentanyl:

Naloxone/Narcan- 0.001-0.015 mg/kg/dose IV. May repeat if needed.

 

Rocuronium/Vecuronium:

Neostigmine- 0.025-0.1mg/kg/dose. Give in combination with atropine as can cause bradycardia.

Atropine 0.02 mg/kg IV