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Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates

Background: We previously reported a 67% extubation failure with INSURE (Intubation, Surfactant, Extubation) using morphine as analgosedative premedication. Remifentanil, a rapid- and short-acting narcotic, might be ideal for INSURE, but efficacy and safety data for this indication are limited. Obje...

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Autores principales: Audil, Hadiyah Y., Tse, Sara, Pezzano, Chad, Mitchell-van Steele, Amy, Pinheiro, Joaquim M. B.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: MDPI 2018
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977045/
https://www.ncbi.nlm.nih.gov/pubmed/29789465
http://dx.doi.org/10.3390/children5050063
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author Audil, Hadiyah Y.
Tse, Sara
Pezzano, Chad
Mitchell-van Steele, Amy
Pinheiro, Joaquim M. B.
author_facet Audil, Hadiyah Y.
Tse, Sara
Pezzano, Chad
Mitchell-van Steele, Amy
Pinheiro, Joaquim M. B.
author_sort Audil, Hadiyah Y.
collection PubMed
description Background: We previously reported a 67% extubation failure with INSURE (Intubation, Surfactant, Extubation) using morphine as analgosedative premedication. Remifentanil, a rapid- and short-acting narcotic, might be ideal for INSURE, but efficacy and safety data for this indication are limited. Objectives: To assess whether remifentanil premedication increases extubation success rates compared with morphine, and to evaluate remifentanil’s safety and usability in a teaching hospital context. Methods: Retrospective review of remifentanil orders for premedication, at a large teaching hospital neonatal intensive care unit (NICU). We compared INSURE failure rates (needing invasive ventilation after INSURE) with prior morphine-associated rates. Additionally, we surveyed NICU staff to identify usability and logistic issues with remifentanil. Results: 73 remifentanil doses were administered to 62 neonates (mean 31.6 ± 3.8 weeks’ gestation). Extubation was successful in 88%, vs. 33% with morphine premedication (p < 0.001). Significant adverse events included chest wall rigidity (4%), one case of cardiopulmonary resuscitation (CPR) post-surfactant, naloxone reversal (5%), and notable transient desaturation (34%). Among 137 completed surveys, 57% indicated concerns, including delayed drug availability (median 1.1 h after order), rapid desaturations narrowing intubation timeframes and hindering trainee involvement, and difficulty with bag-mask ventilation after unsuccessful intubation attempts. Accordingly, 33% of ultimate intubators were attending neonatologists, versus 16% trainees. Conclusions: Remifentanil premedication was superior to morphine in allowing successful extubation, despite occasional chest wall rigidity and unfavorable conditions for trainees. We recommend direct supervision and INSURE protocols aimed at ensuring rapid intubation.
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spelling pubmed-59770452018-05-31 Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates Audil, Hadiyah Y. Tse, Sara Pezzano, Chad Mitchell-van Steele, Amy Pinheiro, Joaquim M. B. Children (Basel) Article Background: We previously reported a 67% extubation failure with INSURE (Intubation, Surfactant, Extubation) using morphine as analgosedative premedication. Remifentanil, a rapid- and short-acting narcotic, might be ideal for INSURE, but efficacy and safety data for this indication are limited. Objectives: To assess whether remifentanil premedication increases extubation success rates compared with morphine, and to evaluate remifentanil’s safety and usability in a teaching hospital context. Methods: Retrospective review of remifentanil orders for premedication, at a large teaching hospital neonatal intensive care unit (NICU). We compared INSURE failure rates (needing invasive ventilation after INSURE) with prior morphine-associated rates. Additionally, we surveyed NICU staff to identify usability and logistic issues with remifentanil. Results: 73 remifentanil doses were administered to 62 neonates (mean 31.6 ± 3.8 weeks’ gestation). Extubation was successful in 88%, vs. 33% with morphine premedication (p < 0.001). Significant adverse events included chest wall rigidity (4%), one case of cardiopulmonary resuscitation (CPR) post-surfactant, naloxone reversal (5%), and notable transient desaturation (34%). Among 137 completed surveys, 57% indicated concerns, including delayed drug availability (median 1.1 h after order), rapid desaturations narrowing intubation timeframes and hindering trainee involvement, and difficulty with bag-mask ventilation after unsuccessful intubation attempts. Accordingly, 33% of ultimate intubators were attending neonatologists, versus 16% trainees. Conclusions: Remifentanil premedication was superior to morphine in allowing successful extubation, despite occasional chest wall rigidity and unfavorable conditions for trainees. We recommend direct supervision and INSURE protocols aimed at ensuring rapid intubation. MDPI 2018-05-22 /pmc/articles/PMC5977045/ /pubmed/29789465 http://dx.doi.org/10.3390/children5050063 Text en © 2018 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
spellingShingle Article
Audil, Hadiyah Y.
Tse, Sara
Pezzano, Chad
Mitchell-van Steele, Amy
Pinheiro, Joaquim M. B.
Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates
title Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates
title_full Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates
title_fullStr Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates
title_full_unstemmed Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates
title_short Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates
title_sort efficacy, safety, and usability of remifentanil as premedication for insure in preterm neonates
topic Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977045/
https://www.ncbi.nlm.nih.gov/pubmed/29789465
http://dx.doi.org/10.3390/children5050063
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