Abstract
Background: The AAP recommends premedication with an analgesic and consideration of a paralytic medication prior to non-emergent intubations in the NICU. Premedication use is inconsistent in both the medications given and the frequency of use, with low paralytic use.|Purpose: The purpose of this quality improvement project was to implement a rapid sequence intubation (RSI) guideline, in the neonatal intensive care unit (NICU), to improve utilization of premedication for intubation in accordance with the American Academy of Pediatrics (AAP) recommendations.|Setting and Participants: This quality improvement project was implemented in a midwestern level III NICU. All intubations performed in the NICU, excluding intubations completed in the delivery room or done on infants with upper airway abnormalities, were reviewed for premedication use. The number of intubation attempts for one year pre- and post-implementation was also evaluated.|Methods: Education on RSI with atropine, fentanyl, and rocuronium was provided to NICU nurses, nurse practitioners, and neonatologists. An electronic health record order set was developed and medications were added to the automated medication dispensing system. Data was collected through review of the electronic medical record.|Results: The pre-implementation group included 63 participants. Thirty-seven percent received fentanyl alone or in combination with atropine or a benzodiazepine. One infant received premedication with atropine, fentanyl, and vecuronium, who required only one intubation attempt. Intubation attempts without premedication averaged 1.4 attempts, and premedication including fentanyl averaged 2.5 attempts. The post-implementation group included 56 participants. eleven percent (n=6) received either fentanyl alone or fentanyl and atropine. Sixteen percent (n=9) received RSI with atropine, fentanyl, rocuronium. There was less variability in medications used, but variations in medication dosing persisted. Intubation attempts without medication averaged 1.9 attempts and intubations with fentanyl alone or fentanyl and atropine averaged 2.4 attempts. Intubations using the RSI guideline decreased to an average of 1.2 attempts.|Conclusion: A premedication guideline alone does not increase utilization of RSI. Premedication use with RSI does decrease the number of intubation attempts.