Intubation in the delivery room: experience with nasal midazolam

Background: Neonates are often intubated in the delivery room (DR) without anesthesia because vascular access is impossible.

Aims: To assess neonatal comfort and adverse events after use of nasal midazolam (nMDZ) for intubation in the DR.

Study design: Prospective data collection over 6months on the intubation of neonates with respiratory distress requiring tracheal instillation of surfactant.

Subjects: Twenty-seven neonates with median (Q25-75) gestational age and birthweight of, respectively, 29 (27-33)weeks and 1270 (817-1942)g received a 0.1mg/kg dose of nMDZ, and intubation was performed at the onset of tonus resolution or apnea.

Outcome measures: Comfort was assessed with a scale of hetero-pain assessment and electrical skin conductance monitoring. Continuous pulse oximetry was recorded in the first postnatal hour, with oscillometric blood pressure measurement every 10min.

Results: Seventy percent of the patients required a single dose, with intubation performed 4.8 (3-9)min after administration. Combined electro-clinical assessment found adequate comfort during the procedure in 68% of neonates. Mean blood pressure decreased from 39 (34-44)mmHg before to 31 (25-33)mmHg 1h following nMDZ (p=0.011).

Conclusion: nMDZ provided rapid and effective sedation to intubate neonates in the DR but potentially exposed them to hypotension, thus requiring close hemodynamic monitoring.