Drugs for elective intubation

Background: Most babies who need intubation at birth are floppy and deeply unconscious and have no need of sedation to achieve intubation, which is usually very easy in these circumstances. However, elective intubation or reintubation on the nursery is made much easier for the operator and much more pleasant for the baby by using sedation, pain relief and a brief period of paralysis. Even small babies can struggle very effectively during intubation making this simple task very difficult. Struggling may result in surges in blood pressure and stress hormones that are best avoided.

In rare circumstances it may be decided to intubate a baby electively without sedation – for example to give surfactant with a view to managing on nCPAP – but this will only be done by someone with considerable experience of intubation and under consultant supervision.

BEFORE PROCEEDING WITH ANY ELECTIVE INTUBATION SPEAK DIRECTLY TO THE NEONATAL CONSULTANT ON CALL

The standard drug regimen for elective intubation in Sunderland NNU is the order as follows:

Morphine, 120 microgram/Kg IV (loading dose – allow 2 minutes prior to administration of remaining drugs)

Midazolam, 100 microgram/Kg slowly IV (for hypnosis, sedation)

Atracurium, 500 microgram/Kg IV (for paralysis)

This regimen should be used for all elective intubations including the change from an oral to a nasal tube on transfer to the nursery from labour ward.

Morphine takes a few minutes to produce an analgesic effect. ALWAYS CHECK THE STRENGTH OF THE STOCK SOLUTION BEFORE YOU START – The standard morphine stock solution in NNU should be 1 mg in 5 ml or 200 microgram/ml. Thus you will need 0·6 ml of this standard solution for each kilogram the baby weighs.

Sometimes we are supplied with a morphine solution containing 10 mg in 1ml. This will need to be diluted before use. Take 0·2 ml (2 mg) and make up to 10 ml with water for injection. This will give you a solution containing 200 micrograms per ml. You will then need 0·6ml of this diluted solution for each kilogram the baby weighs.

Midazolam is a benzodiazepine, which is rapidly taken up by fat and therefore has a short duration of action after single dose administration even though it has a 12-hour half-life in the newborn. Multiple doses lead to accumulation. ALWAYS CHECK THE STRENGTH OF THE STOCK SOLUTION BEFORE YOU START– the standard midazolam stock solution in NNU should be 2 mg in 2 ml, the following diluting instructions are only appropriate for this standard stock solution – Take 1 ml (1 mg) and dilute to 10 ml with saline or dextrose saline which will give you a solution containing 100 microgram per ml.You will then need 1ml of this diluted solution for each kilogram the baby weighs.

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