Evidence summary
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Efficacy:
Premedication for intubation: Durrmeyer et al 2018 [1] in an RCT in 173 neonates undergoing non-emergency, nasotracheal intubation, the frequency of prolonged desaturation did not differ between infants receiving atropine 15 microgram/kg + propofol 2.5 mg/kg [infants >1000 g] or 1 mg/kg [infants <1000g ] + additional propofol dose 1 mg/kg if needed, compared to infant, receiving atropine 15 microgram/kg + atracurium 0.3 mg/kg + additional 0.1 mg/kg + sufentanil 0.2 microgram/kg [>1000 g] or 0.1 microgram/kg [<1000 g]. The atropine-propofol group had longer mean procedure duration, less frequent excellent quality of sedation, shorter median time to respiratory recovery, shorter time to limb movement recovery (18 versus 60 minutes) and SpO2 was preserved better in the following hour.van der Lee et al 2016 [2] in n RCT in 22 very preterm newborns undergoing intubation premedicated with morphine 0.1 mg/kg + vecuronium 0.1 mg/kg versus propofol 2 mg/kg reported significant hypotension in one infant receiving propofol and no difference in intubating condition score between groups.
Penido et al 2011 [3] in an RCT in 20 preterm neonates who underwent tracheal intubation following the use of remifentanil 1 µg/kg + either propofol 2 mg/kg or midazolam 200 µg/kg reported excellent conditions to intubate were observed in 3 neonates that received midazolam and 4 who received propofol, a second attempt to intubate was necessary in 3 patients infused with midazolam and in 2 patients infused with propofol. No differences in pain and stress level before and after the intubation using the NIPS scale and the COMFORT scales. Ghanta et al 2007 [4] reported propofol 2.5 mg/kg (maximum 2 doses) was more effective than morphine 100 microgram/kg atropine, 10 microgram/kg + suxamethonium 2 mg/kg (maximum total dose of 4 mg/kg per intubation attempt) as an induction agent to facilitate neonatal nasotracheal intubation. Time to intubation and recovery time was shorter, hypoxaemia less severe and nasal trauma reduced.
Simons et al 2013 [5] in a case series of 62 intubations in neonates 24 to 44 weeks and 520 to 4380 g assessed premedication with propofol 2 mg/kg starting dose. This was sufficient in 37%. Additional propofol was needed less often on the first postnatal day. The mean dose was 3.3 (SD 1.2) mg/kg. Hypotension occurred in 39%. In 15% of procedures, propofol monotherapy was insufficient.
Conclusion: Propofol with or without the addition of an opioid reduces infant stress and pain and results in improved intubation conditions and relatively short time to recovery. Its use is associated with apnoea, need for assisted ventilation and hypotension. It is not clear if its safety profile warrants its use in newborn infants. (LOR II GOR D)
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