Rapid Sequence Intubation
in the NICU
Barriers to Policy
and Procedure change
Intubating Conditions
Ethics
Emergency
Non-Emergency
Would we intubate adult
patients without sedation or analgesia?
Current Recommendations
American Academy of Pediatrics Recommendation
- 2010 AAP released clinical report for premedication for non-emergent endotracheal intubations in the neonate
- Except for emergent intubation during resuscitation either in the delivery room or after acute deterioration or critical illness at a later age, premedication should be used for all endotracheal intubations in newborns
Long term effects of pre-medications are unknown
Potential Gaps
in Knowledge
IV access not available
- IM route consideration
Medications
Analgesic agents or anesthetic dose of a hypnotic drug should be given
Vagolytic agents and rapid-onset muscle relaxants should be considered.
Use of sedative alone such as benzodiazepines without analgesia should be avoided
A muscle relaxant without an analgesic agent should not be used
Feasibility of access to medications
Delivery room intubations
Provider/staff knowledge
Proven Benefits
Facilitate better intubating conditions
Decrease the number and times of attempts
Fewer changes in baseline heart rate/ blunting of SNS stimulation
Decreased number of intubation-realated airway truma
Neonates experience with intubation
Hypoxemia
Bradycardia
Increased ICP - higher risk of IVH
Systemic and pulmonary hypertension
Potential damage to airway with laryngoscopy
Medications with rapid onset and short duration of action are preferable
- What are the best choice of medications?
- What is the best sequence of administration?
- Time and speed of administration?
RSI specific kits?
Excellent Intubating Conditions
- Good jaw relaxation
- Open and immobile vocal cords
- Suppression of pharyngeal and laryngeal reflexes by blunting coughing or diaphragmatic movement in response to intubation
Provider/staff attitude
Resources
Habit
Fear of chest wall rigidity
Multidisciplinary Planning
Pharmacy involvement to ensure access to overriding medication or medication availability in a timely fashion
Lists of preferred medications to improve compliance and minimize medication errors and adverse events
Protocol development
Creation of order set