Premedication for Intubation


Reviewed by Clinical Practice Committee
June 2015
Clinical Guidelines Back Newborn Services Home Page

Most intubations occur at the time of delivery in the process of resuscitation, or semi-electively in infants with either poor respiratory effort or with severe immediate respiratory distress in the immediate newborn period. Intubation medications are therefore not usually given. However, once the infant is in the NICU environment and IV access is obtained, the use of intubation agents for elective or semi-elective intubations should be considered, particularly in large vigorous infants.

Contraindications and Precautions

1.  Intubation drugs should not be used
  • if there is a known allergy to any of the agents
2.  Suxamethonium should not be used
  • if there is a family history of malignant hyperthermia
  • if there is a suspicion of muscular dystrophy, or
  • if there is significant hyperkalaemia
3.Suxamethonium should be used with caution
  • if there is concern that the infant has abnormal upper airway anatomy (for example, severe micrognathia) and that intubation may be technically extremely difficult.
    • In this situation, a consultant (and potentially an ENT surgeon) should also be present.

Preparation and Equipment

  1. Consider intubation drug use in all elective or semi-elective intubations where IV access is available or can easily be obtained.
  2. Premedication should be strongly considered for all vigorous term infants.
  3. Equipment must be ready, especially the bag-mask circuit and laryngoscope. The infant will have no spontaneous respiratory effort once muscle relaxing agents (or Fentanyl) have been given.
  4. Suxamethonium should not be given if there is significant hyperkalaemia.
  5. If Fentanyl is given, Suxamethonium should be ready to be given if chest-wall rigidity occurs.
  6. Medications should be administered in the order of:

    See Intubation Quick Reference Guide.
    Anticholinergic  Atropine 20mcg/kg IV
    (if given)
    Sedation Fentanyl 4mcg/kg IV Give slowly (30 seconds) to avoid muscle rigidity
    Allow at least 30 seconds for sedation
    Muscle relaxation Suxamethonium 2mg/kg IV
    (if given)

    If Morphine is used instead of Fentanyl, drugs should be administered in the order of

        Morphine, then Atropine, then Suxamethonium

  7. The infant should have bag-mask ventilation during the administration of Fentanyl and Suxamethonium, or prior to this if respiratory effort is poor.
  8. Laryngoscopy should commence once spontaneous respiratory movements have ceased.
  9. Muscle fasciculation from Suxamethonium administration does not occur in neonates and should not be relied upon as a sign of successful neuromuscular blockade.
  10. If bradycardia occurs in the presence of hypoxaemia, a second dose of Atropine should not be given. The bradycardia is due to inadequate oxygenation and/or ventilation.
  11. If the intubation is unsuccessful, Suxamethonium can be re-administered but Atropine and Fentanyl should not be repeated.

To view a literature review and rationale for this protocol, click here