Facilitation of neonatal endotracheal intubation with mivacurium and fentanyl in the neonatal intensive care unit

Background: Endotracheal intubation in the neonate is painful and is associated with adverse physiological effects. Some premedication regimens have been shown to reduce these effects, but the optimal regimen is not yet determined. Method: Data on semi-elective intubations were prospectively collected in the neonatal intensive care unit over a six month period. Patients received 20 μg/kg atropine, 200 μg/kg mivacurium (a non-depolarising muscle relaxant) followed by 5 μg/kg fentanyl. Results: Thirty three patients were electively intubated during this time period. The primary reason for intubation was surfactant administration (53%). Median (range) birth weight, gestational age, and age at intubation were 1360 g (675-4200), 29 weeks (25-38), and 33 hours (1-624) respectively. Twenty two of the infants were intubated on the first attempt. Median duration from initial insertion of the laryngoscope to successful intubation was 60 seconds (15 seconds to 20 minutes). In 18 cases, the first attempt was by a trainee with no previous successful intubation experience, 10 of whom intubated within two attempts. Muscle relaxation occurred at a mean (SD) of 94 (51) seconds, and mean (range) time to return of spontaneous movements was 937 seconds (480-1800). Intubation conditions were scored as excellent using a validated intubation scale. Conclusion: Effective analgesia can be administered and intubation performed with some brief desaturations, even when junior personnel are being taught their first intubation. In this first report of mivacurium for intubation in the newborn, effective bag and mask ventilation was easily achieved during muscle relaxation and was associated with excellent intubation conditions, permitting a high success rate for inexperienced personnel.