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