WIP 24 - Improving Intubation Premedication Use in Infants ≤1500g

Publication Number: WIP 24.7604

Josh J.. Daniel, Yale School of Medicine, New Haven, CT, United States; Cassandra DeMartino, Yale School of Medicine, New Haven, CT, United States; Noa Fleiss, Yale-New Haven Children's Hospital, New Haven, CT 06510, CT, United States; Lindsay Johnston, Yale School of Medicine, New Haven, CT, United States

Background: Neonatal endotracheal intubation can be a lifesaving procedure, however, it can require multiple attempts and lead to potential adverse tracheal intubation associated events (TIAEs). Premedication, especially with a paralytic, have been shown to improve intubation safety and decrease the number of attempts. When a rapid sequence intubation (RSI) protocol (combination of a vagolytic, analgesic, and paralytic) was introduced at our level IV NICU, it was only for infants >1,000g to evaluate safety and ensure provider comfort. Premedication was only occasionally used for infants ≤1500g due to the unit protocol and perceived safety concerns. Given the mounting evidence of benefit in using premedication, we plan to expand our practice and include this higher-risk infant population.

Objective: We aim to improve the use of intubation premedication for non-emergent intubations in infants ≤1500g from 31.2% to 60% and full RSI use from 16.5% to 60% over a 6-month period (from Oct 2024-Apr 2025). We also aim to reduce the total number of TIAEs and severe desaturations by 10% (from 39% to 29% and from 35% to 25%, respectively), and reduce the number of intubation attempts (from a mean of 2.2 to 1.5).

Design/Methods: A retrospective analysis from Jan 2020-Jul 2024 was conducted and a total of 369 intubation encounters were included. Any infant who was intubated in the delivery room, emergently intubated, or had known or suspected difficult airways, were excluded. Out of these 369 intubation encounters, only 16.5% (61/369) received RSI. For infants who did not receive any premedication, 39.2% had a TIAE, 3% had a severe TIAE, and 34.5% had a severe desaturation (≥20% decrease from baseline). For infants who received RSI, 13.1% had a TIAE, 0% had a severe TIAE, and 8% had a severe desaturation. To initiate this quality improvement initiative, a premedication multidisciplinary team was assembled in Oct 2024. Targeted education on the benefits of RSI was conducted and an RSI Epic-based clinical pathway and order set was created. This study was deemed exempt from IRB oversight.