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A full term infant born out of asepsis (BOA) at home is brought in by ambulance to your PED. No neonatologist or pediatrician is in house. The baby’s venous blood gas shows a pH of 6.9, PCO2 80. The baby has inadequate respirations. Which do you decide to do?
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February 28, 2021 at 11:39 pm
Although there have been calls for use of sedatives and analgesics pre-intubation in neonates for ethical reasons, surveys have shown that neonates are still often intubated with no premedication. Some studies have shown increased rates of bradycardia and elevated ICP when neonates are intubated without medications vs. with. Studies have also shown better success when RSI medications are used. However, these studies are primarily for elective non-emergent intubations. Several of the medications commonly used by EP’s for RSI carry caveats for neonates. Fentanyl is a popular choice for pediatric RSI but there is an increased risk of chest wall rigidity in neonates. Morphine may be an alternative, or, when using a paralytic as well there is less concern about chest wall rigidity. There are concerns for adrenal suppression with etomidate and increased adverse effects with propofol. Succinylcholine, when used, may be needed at a higher dose than usual – up to 2 mg/kg, and while routine atropine pretreatment has fallen out of favor for pediatric RSI, it may be indicated in neonatal RSI when using succinylcholine. Finally, because neonates can be difficult to intubate, there are concerns when using paralytics regarding taking away the infant’s ability to breathe on his/her own.
– Carbajal R, Eble B, Anand KJ. Premedication for tracheal intubation in neonates: confusion or controversy? Semin Perinatol. 2007 Oct;31(5):309-17. doi: 10.1053/j.semperi.2007.07.006. PMID: 17905186.
– Bottor LT. Rapid sequence intubation in the neonate. Adv Neonatal Care. 2009 Jun;9(3):111-7; quiz 118-9. doi: 10.1097/ANC.0b013e3181a68cd4. PMID: 19542772.