Congratulations! You have made it successfully to 2021! While 2020 was challenging for EVERYONE, and may have required some brute force to endure, let us take this opportunity to consider avoiding using brute force (“Brutane“) when intubating our smallest of patients – neonates. Certainly, I have used more brutane in my training and career than I should care to admit… but I am old… but, unfortunately, we all know that this is still taught and depicted today. Why? There are a variety of explanations, after all neonates are kinda scary, but we have better resources and interventions today. Let us review Neonatal Intubation and Medications for RSI:

Neonatal Intubation: It isn’t Comfortable for Anyone

Neonates epitomize all of the characteristics of a “Difficult Airway.”

• Challenging anatomy
  • VERY Small, compressible airway
  • Relatively large tongue and occipital area
• Challenging physiology
  • Low Functional Residual Capacity
  • High metabolic rate and oxygen consumption

Often an anticipated “Difficult Airway” may make clinicians reluctant to administer medications like paralytics or sedatives…

• With an elective procedure, this may make sense, but when we consider intubating a patient (of any age) in the ED, it is not typically related to an “elective case” that can be cancelled and rescheduled… and we need to make our first attempt the best attempt.
• With neonates, specifically, not using medications may actually make it MORE Difficult! (actually, kinda true for all ages.) [Foglia, 2019; Ozawa, 2019; Fiadjoe, 2019]

Neonates do feel pain! [McPherson, 2020]

• The notion that neonates are too small, too young, and too immature to perceive pain or have it lead to lasting consequences has long been refuted…
• We have previously discussed this with respect to performing LPs.
• Certainly, having a laryngoscope shoved down a neonate’s throat would cause more than just bradycardia!
• Don’t be cruel.

Neonatal intubations are difficult: [Foglia, 2019]

• Data from an international registry from 10 academic neonatal centers shows that:
  • First attempt success rate were 49% in NICUs and 46% in Delivery Rooms
  • Complications and adverse events are not uncommon (18% in NICUs and 17% in Delivery Rooms).
  • Severe Desaturations rates ranged from 29% to 69%, depending on individual sites.
• This data set does not include Emergency Departments (and there really isn’t much literature specifically including the ED), focusing instead on NICUs and Delivery Rooms.

There is CONSIDERABLE variation in practice amongst providers during neonatal intubations. [Wheeler, 2012]

Neonatal Intubation: Brutane vs Brains

While brawn may overpower a neonate’s jaw muscles, it does not make intubation easier… as it is more complex than just getting past the mouth. [Foglia, 2019; Ozawa, 2019; Fiadjoe, 2019]

Let’s consider what is known and use our brains instead:

• In 2736 neonatal intubations, [Ozawa, 2019]
  • 36% used NO medications.
  • 47% of the intubations used paralytic and sedative.
  • Those intubations performed with both paralytic and sedative had statistically significant fewer adverse events than either sedative alone or no medication.
• The international registry found modifiable, independent factors associated with reduced odds of adverse events to be : [Foglia, 2019]
  • Paralytic use
  • Video laryngoscopy use
• Sedative use ALONE, without paralytic [Foglia, 2019]
  • is NOT protective against adverse events.
  • is associated with increase odds of severe oxygenation desaturations.
• “Paralytic use, when appropriate, is an important component of a procedural premedication regimen to improve the safety of neonatal intubation.” [Foglia, 2019]

Moral of the Morsel

• Don’t be a Brute! It may seem easier, but in the end, “Brutane” makes your job more difficult and makes the child suffer!
• Don’t go half way. Using only a sedative is not better! Use both paralytic and sedative concurrently.
• HAPPY NEW YEAR! Let’s continue to remain vigilant and strive to care for all of our patients with the respect and compassion each of us deserves.

References