Does Propofol Prevent Prolonged Desaturation During Neonatal Intubation?

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Oxygen saturation appeared to be better preserved, and the spontaneous respiration and limb movements recovered faster in the atropine-propofol group
Oxygen saturation appeared to be better preserved, and the spontaneous respiration and limb movements recovered faster in the atropine-propofol group

The frequency of prolonged desaturations did not differ significantly when atropine was used with propofol or with atracurium and sufentanil in neonates undergoing nonemergency tracheal intubation, according to the results of a randomized double-blind clinical trial published in the Journal of the American Medical Association.

Xavier Durrmeyer, MD, PhD, from the Neonatal Intensive Care Unit, CHI Creteil, France, and colleagues conducted the study in 6 neonatal intensive care units in France (ClinicalTrials.gov Identifier: NCT01490580).

The investigators randomly assigned 173 neonates (71 girls) who required nonemergency intubation to atropine-propofol (n=89) or atropine-atracurium-sufentanil (n=82) before nasotracheal intubation. The primary outcome was prolonged desaturation, defined as pulse oximetry (Spo2) <80%, lasting >60 seconds.

The mean gestational age of the infants was 30.6 weeks, and the mean birth weight was 1502 g. Prolonged desaturation occurred in 59.6% of atropine-propofol-treated infants, and in 65.9% of those treated with atropine-atracurium-sufentanil. This was not a significant difference.

As for secondary outcomes, the mean duration of the intubation procedure was significantly longer in infants treated with atropine-propofol at 6.6 minutes than in the atropine-atracurium-sufentanil group at 4.9 minutes (P =.04). The quality of sedation was also superior in the atropine-atracurium-sufentanil group, with 92.6% achieving an excellent quality of sedation vs 51.7% in the atropine-propofol group (P <.001).

However, the median time to spontaneous respiration recovery was 14 minutes in the atropine-propofol group vs 33 minutes in the atropine-atracurium-sufentanil group (P =.002), whereas the median time to limb movement recovery was 18 minutes in the atropine-propofol group and 36 minutes in the atropine-atracurium-sufentanil group (P =.003).

Head ultrasound scans showed worsening intracranial hemorrhage in 20.6% of the atropine-propofol group and 17.6% of the atropine-atracurium-sufentanil group, but this difference was not significant. In the hour after inclusion, Spo2 was preserved significantly better in the atropine-propofol group (P =.02).

Serious adverse events occurred in 11% of the atropine-propofol group and 20% of the atropine-atracurium-sufentanil group.

The authors noted that the Spo2 appeared to be better preserved and spontaneous respiration and limb movements recovered faster in the atropine-propofol group, but reinjection was required much more often than in the atropine-atracurium-sufentanil group. Furthermore, mean arterial blood pressure was better, duration of intubation shorter, and quality of sedation superior in the atropine-atracurium-sufentanil group, although severe adverse events were more frequent than in the atropine-propofol group.

The authors questioned the potential for increased pain when a muscle relaxant is used, as this prevents opioid titration. The prolonged increased heart rate noted in the atropine-atracurium-sufentanil group may indicate inadequate pain relief. Of concern, increased pain during the neonatal period correlates with poorer neurodevelopmental outcomes.

The authors suggested that the failure to find a significant difference in the frequency of prolonged desaturation may be the result of the study being underpowered, and they recommended further research in this area.

Reference

Durrmeyer X, Breinig S, Claris O, et al. Effect of atropine with propofol vs atropine with atracurium and sufentanil on oxygen desaturation in neonates requiring nonemergency intubation. JAMA. 2018;319:1790-1801.

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