piperidines and Respiratory-Distress-Syndrome--Newborn

To evaluate the efficacy and safety of remifentanil as a premedication in neonates undergoing elective endotracheal intubation.. A double-blind randomised controlled trial.. Tertiary care neonatal intensive care unit.. Haemodynamically stable term and preterm neonates requiring elective endotracheal intubation.. Infants in the intervention arm received remifentanil (3 microg/kg) and normal saline placebo. The control group received fentanyl (2 microg/kg) and succinylcholine (2 mg/kg). Both groups also received atropine (20 microg/kg) as part of the premedication regime.. The primary outcome was time to successful intubation. Secondary outcomes included time to return of spontaneous respirations, oxygen saturation, heart rate and blood pressure changes during the procedure, adverse events and a survey of intubation conditions.. A total of 15 infants were randomised to each group. Baseline characteristics were similar in both groups. The median time to successful intubation was not statistically different (247 s in the remifentanil group vs 156 s in the fentanyl group, p=0.88). The intubation conditions were rated more favourably with fentanyl by the intubators. Although not statistically significant, chest wall rigidity was observed more commonly with remifentanil.. Although remifentanil is comparable to fentanyl and succinylcholine in attenuating adverse physiologic responses during neonatal intubation, muscle rigidity is a concern at doses of 3 microg/kg. Further trials are required to evaluate ideal dosing regimens and combinations of agents for use with remifentanil in neonates.

Topics: Analgesics, Opioid; Double-Blind Method; Female; Humans; Infant, Newborn; Infant, Premature; Intensive Care, Neonatal; Intubation, Intratracheal; Male; Piperidines; Premedication; Remifentanil; Respiratory Distress Syndrome, Newborn; Respiratory Insufficiency

Morphine is one of the most commonly used drugs for sedation and analgesia during mechanical ventilation, but its pharmacological profile has limitations, such as prolonged duration of action, especially in premature neonates. Because of its very short context-sensitive half-time, remifentanil has rapid onset and quickly decreases in plasma concentration after interrupting administration. The aim of the present study was to compare a continuous infusion of remifentanil and morphine during mechanical ventilation of premature neonates with respiratory distress syndrome (RDS).. Twenty premature neonates (28-34 weeks) with RDS were randomized in a prospective double-blinded study to receive either a continuous infusion of morphine (n = 10) or remifentanil (n = 10) for mechanical ventilation. The length of time to awaken and extubate the neonate after interrupting opioid administration was recorded. We also recorded stress (COMFORT scale), pain response [Neonatal Infant Pain Scale (NIPS)], hemodynamic and ventilatory variables as well as adverse effects secondary to infusion of the specific opioid.. After terminating infusion, the length of time required to awaken and extubate the neonates was 18.9- and 12.1-fold longer, respectively, in the morphine group than in the remifentanil group. Both groups produced good quality sedation and analgesia as evaluated by the NIPS and COMFORT scores. No major side effects were observed.. Our results show an interesting potential for the use of remifentanil in premature neonates. Remifentanil allowed an adequate level of sedation and analgesia as well as rapid recovery after discontinuation. However, further properly designed clinical trials are needed before it can be generally recommended.

Topics: Adult; Analgesics, Opioid; Anesthesia Recovery Period; Conscious Sedation; Double-Blind Method; Female; Hemodynamics; Humans; Hypnotics and Sedatives; Infant, Newborn; Infant, Premature; Infusions, Intravenous; Male; Maternal Age; Morphine; Piperidines; Remifentanil; Respiration, Artificial; Respiratory Distress Syndrome, Newborn; Time Factors

A double-blind, randomised controlled study was conducted to evaluate the intubation conditions in 20 preterm neonates following the use of either morphine or remifentanil as premedication. The findings suggest that the overall intubation conditions were significantly better (p=0.0034) in the remifentanil group than in the morphine group. No severe complications were observed in either group.

Topics: Analgesics, Opioid; Conscious Sedation; Double-Blind Method; Humans; Infant, Newborn; Infant, Premature; Intubation, Intratracheal; Morphine; Piperidines; Remifentanil; Respiratory Distress Syndrome, Newborn

Neonatal intubation is stressful and should be performed with premedication. In the case of an INSURE (intubation/surfactant/extubation) procedure a short duration of action of the premedication used is needed to facilitate fast extubation. Given its pharmacological profile, remifentanil seems a suitable candidate.. The aim here was to evaluate the effect and side effects of remifentanil as a premedication for preterm neonates undergoing INSURE.. A prospective, single-center study in a level III neonatal intensive care unit was conducted. The quality of sedation was assessed in preterm infants receiving remifentanil prior to intubation for the INSURE procedure. Intravenous remifentanil was administered quickly and followed by a saline flush in approximately 30 s. The quality of sedation was defined by a combination of adequate sedation score, good intubation conditions and absence of side effects.. The study was terminated after the inclusion of 14 patients because of the high rate of side effects and the poor intubation conditions. Adequate sedation was achieved in only 2 patients (14%). Six patients (43%) needed additional propofol to obtain adequate sedation. Chest wall rigidity occurred in 6 patients (43%).. The rapid administration of remifentanil provides insufficient sedation and is associated with a high risk of chest wall rigidity in preterm neonates.

Topics: Female; Humans; Hypnotics and Sedatives; Infant, Newborn; Infant, Premature; Intubation, Intratracheal; Male; Netherlands; Piperidines; Propofol; Prospective Studies; Pulmonary Surfactants; Remifentanil; Respiration, Artificial; Respiratory Distress Syndrome, Newborn; Treatment Failure

To evaluate intubating conditions, extubation times and outcome in preterm infants receiving remifentanil as induction agent for the INSURE procedure.. In twenty-one preterm infants of 29 to 32 weeks gestation and signs of respiratory distress, we utilized remifentanil as induction agent for the INSURE procedure. Following intubation and surfactant application, the infants were mechanically ventilated until respiratory drive was judged to be satisfactory for continuing CPAP therapy. Intubating conditions were classified by our own scoring system by rating limb movements, coughing and breathing. Heart rate, blood pressure and oxygen saturation were recorded during the entire INSURE procedure.. Remifentanil provided excellent or good intubating conditions in all patients. We observed no serious side effects after remifentanil infusion, in particular, no thorax rigidity, clinically significant bradycardia or arterial hypotension. Average extubation time after surfactant administration was 16.9 min (1-45 min); none of the infants had to be reintubated. Following extubation, the infants required only 3.3 days (1-8 days) of CPAP therapy. None exhibited serious complications of prematurity like periventricular leucomalacia, intraventricular haemorrhage >I degree, necrotizing enterocolitis or retinopathy.. In this pilot study, INSURE with remifentanil was associated with good intubating conditions and early extubation resulting in an excellent neonatal outcome.

Topics: Analgesics, Opioid; Continuous Positive Airway Pressure; Humans; Infant, Newborn; Infant, Premature; Intubation, Intratracheal; Pilot Projects; Piperidines; Pulmonary Surfactants; Remifentanil; Respiration, Artificial; Respiratory Distress Syndrome, Newborn; Treatment Outcome

To assess efficacy of remifentanil in preterm newborns during mechanical ventilation.. Remifentanil was administered by continuous intravenous infusion to provide analgesia and sedation in 48 preterm infants who developed respiratory distress and required mechanical ventilation. We examined the doses needed to provide adequate analgesia, extubation time after the discontinuation of opioid infusion, the presence of side effects and safety of the use.. Remifentanil provided adequate analgesia, with a significant reduction of NIPS and COMFORT score since 1 h after starting the infusion of remifentanil. The drug was initially administered at a dose of 0.075 microg/kg/min, but in 73% of newborns the latter had to be increased; at a dose of 0.094 +/- 0.03 (mean +/- standard deviation) microg/kg/min, 97% of the newborns received adequate analgesia and sedation. The time elapsed between the discontinuation of remifentanil infusion and extubation was 36 +/- 12 min. Treatment was started between the 1st and the 17th day of life. The mean duration of therapy was 5.9 +/- 5.7 days. No side effects on the respiratory or cardiovascular system were observed.. Remifentanil is a manageable and effective opioid in the newborn undergoing mechanical ventilation, though randomized controlled trials and information about long-term outcomes are necessary.

Topics: Analgesics, Opioid; Dose-Response Relationship, Drug; Drug Monitoring; Humans; Infant, Newborn; Infant, Premature; Intensive Care Units, Neonatal; Multivariate Analysis; Pain Measurement; Piperidines; Pneumonia; Remifentanil; Respiration, Artificial; Respiratory Distress Syndrome, Newborn; Respiratory Insufficiency; Respiratory Mechanics

Topics: Adult; Anesthesia, Conduction; Anesthesia, General; Anesthesia, Obstetrical; Brain Edema; Cesarean Section; Contraindications; Emergencies; Female; Hemodynamics; Humans; Infant, Newborn; Intracranial Arteriovenous Malformations; Male; Piperidines; Pregnancy; Pregnancy Complications, Hematologic; Pregnancy Trimester, Third; Remifentanil; Respiratory Distress Syndrome, Newborn; Subarachnoid Hemorrhage; Vasospasm, Intracranial; Vertebral Artery

We present the efficacy and safety of the use of remifentanil for intubation, sedation and analgesia in a preterm infant during mechanical ventilation for respiratory distress syndrome. A 34-week-old baby, born by cesarean delivery that developed respiratory distress, required intubation and ventilatory support. For intubation, the baby was given midazolam (0.2 mg.kg(-1)) and remifentanil (1 microg.kg(-1)). The intubation conditions were assessed and classified as excellent. The remifentanil infusion was started at dose 0.75 microg.kg(-1).min(-1) and the dose adjustments were made depending on the neonatal infant pain scale (NIPS), hemodynamic and respiratory changes or the presence of spontaneous movements. Pulse oximetry, respiratory rate, ECG and invasive blood pressure were continuously monitored. He was given surfactant within 2.5 h of life after which ventilator parameters could be progressively decreased. Three hours later, the remifentanil infusion was decreased to 0.5 microg.kg(-1).min(-1), and he remained sedated (NIPS < 2). Six hour after surfactant administration, blood gases and chest X ray were normal. The remifentanil infusion was then discontinued and 30 min later the baby was awake and extubated with success. There were no side effects after intubation or during the continuous infusion. The profile of remifentanil allowing a rapid recovery, the absence of side effects and a good level of sedation and analgesia support the choice of this opioid for sedation in the NICU.

Topics: Analgesics; Analgesics, Opioid; Humans; Hypnotics and Sedatives; Infant; Infant, Newborn; Infant, Premature; Intubation; Male; Midazolam; Pain Measurement; Piperidines; Remifentanil; Respiratory Distress Syndrome, Newborn

Diphemanil can be useful in some neonates presenting with bradycardia due to vagal hyperreflectivity. Paradoxically, this drug may induce atrio-ventricular (AV) block in premature babies.. Case no 1. A premature neonate suffering from acute respiratory distress from birth required respiratory support, antibiotics and caffeine. Despite this treatment, he underwent many episodes of apnea, and bradycardia that appeared on day 4 and did not respond to IV doxapram (1 mg/kg/h). He was given diphemanil on day 9 (10 mg/kg/d) and permanent bradycardia with complete AV block and a normal QT interval appeared 2 days later. Cessation of diphemanil and administration of IV isoprenaline led to a normal sinusal rhythm, but there were bladder, intestinal and ocular signs of atropinic intoxication. A complete definitive recovery occurred 5 days after cessation of diphemanil. Case no 2. A premature neonate developed episodes of apnea 2 days after birth. These episodes persisted and were complicated by bradycardia on day 4 despite administration of caffeine. Vagal stimulation on day 7 was positive and the infant was then given diphemanil (10 mg/kg/d). Permanent bradycardia occurred 2 days later, with partial AV block and a normal QT interval. The child recovered a normal sinusal rhythm 2 days after cessation of diphemanil.. Anticholinergic therapy may cause permanent bradycardia due to AV block in premature infants. This therapy should not be given to premature infants without a prior ECG. Doses lower than those used in infants are recommended.

Topics: Bradycardia; Bronchodilator Agents; Drug Administration Schedule; Heart Block; Humans; Infant, Newborn; Infant, Premature; Male; Parasympatholytics; Piperidines; Respiratory Distress Syndrome, Newborn