254 - Premedication Use for Non-Emergent Intubation of Very Low Birth Weight Infants: A National Survey

Poster Number: 254
Publication Number: 254.3314

Background: Premedication, especially with a muscle relaxant, improves the success of tracheal intubation (TI) and decreases adverse events. However, wide variation exists among neonatal intensive care units regarding intubation premedication practices, particularly regarding the use of muscle relaxants for very low birth weight (VLBW) infants < 1500 g.

Objective: This study aimed to explore provider perspectives on the benefits, barriers, and facilitators to the use of premedication for VLBW infants undergoing non-emergent TI.

Design/Methods: We electronically surveyed neonatal providers regarding their use of premedication prior to non-emergent neonatal TI using the AAP Section on Neonatal-Perinatal Medicine listserv. Premedication included analgesics, sedatives, vagolytics, and muscle relaxants. We distinguished between medication use for infants less than or greater than 1500 g at the time of intubation.

Results: A total of 521 neonatal providers (15% response rate) responded to the survey between Jan-Apr 2023. The majority (n=415, 81%) were neonatologists and more than half of respondents (n=285, 55%) had less than 10 years’ experience (table 1). Most providers (n=407, 78%) strongly or somewhat agreed that premedication should be used for non-emergent TI of VLBW infants while only 41% (n=214) similarly felt that muscle relaxants should be used (figure 1). Many providers (n=359, 69%) consider patient weight when selecting premedication for non-emergent TI. Providers who consider patient weight are more likely to use premedication for larger infants, with analgesics used most often (≥ 1,500 g: n=294, 82% and < 1,500 g: n=226, 63%). Providers identified obtaining timely intravenous access (n=401, 77%) and length of time to draw up and/or administer medications (n=354, 68%) as barriers to premedication use for VLBW infants. They identified non-invasive surfactant delivery (e.g., Intubate-SURfactant-Extubate) as a barrier to the use of muscle relaxants for VLBW infants (n=438, 84%). Facilitators of muscle relaxant use included the presence of unit-specific premedication guidelines (p < 0.0001). General premedication use was more favorable when there was an established premedication guideline (p < 0.0001), accessible reversal agents (p=0.05), and available intubation backup (p=0.0004).

Conclusion(s): Most neonatal providers favored the use of premedication for non-emergent TI of VLBW infants, however, the routine use of muscle relaxants is more limited. While multiple barriers exist, protocols with specific guidance on patient weight may facilitate the use of premedication including muscle relaxants for this population.