Clinical Practice Committee
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
Intubation drugs should not be used
there is a known allergy to any of the agents
Suxamethonium should not be used
there is a family history of malignant hyperthermia
- if there is a suspicion of muscular dystrophy, or
- if there is significant hyperkalaemia
should be used with caution
there is concern that the infant has abnormal upper airway anatomy (for
example, severe micrognathia) and that intubation may be technically
- In this situation, a consultant (and potentially an ENT surgeon) should
also be present.
Preparation and Equipment
- Consider intubation drug use
in all elective or semi-elective intubations where IV access is available or can
easily be obtained.
- Premedication should be strongly considered for
all vigorous term infants.
- 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.
- Suxamethonium should not be given if there is
- If Fentanyl is given, Suxamethonium should be ready to
be given if chest-wall rigidity occurs.
- Medications should be administered in the order of:
Quick Reference Guide.
||Give slowly (30 seconds)
to avoid muscle rigidity
Allow at least 30 seconds for sedation
If Morphine is used instead of Fentanyl, drugs should be administered in the
Morphine, then Atropine, then Suxamethonium
- The infant should have bag-mask ventilation during the
administration of Fentanyl and Suxamethonium, or prior to this if respiratory
effort is poor.
- Laryngoscopy should commence once spontaneous respiratory
movements have ceased.
- Muscle fasciculation from Suxamethonium administration
does not occur in neonates and should not be relied upon as a sign of
successful neuromuscular blockade.
- 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.
- 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