Premedication practices prior to neonatal laryngoscopy: a nationwide observational study in Belgian NICUs

Intubation or less invasive surfactant administration (LISA) in neonates both require laryngoscopy, a stressful and painful procedure. This study aimed to document premedication practices before laryngoscopy in Belgium and explore reasons for absence of premedication. Sub-analysis of the SUPREMEneo prospective cohort on premedication before laryngoscopy in neonates, focused on data from all 19 Belgian neonatal intensive care units (NICU) in June 2024. 142 laryngoscopies were included: 91 intubations (14 in an immediate-life-threatening situation) and 51 LISA. Premedication was administered in 56/77 (73%) and 35/51 (69%) laryngoscopies preceding non-life-threatening intubations and LISA, respectively. Premedication was less used in urgent (<10 min) intubations (p=0.04) and those performed in the delivery room (p<0.001 vs NICU). No such differences were observed for delivery room LISA. Both operator status and previous laryngoscopy experience were associated with differences in premedication rates before LISA (p=0.04 and p=0.05, respectively). In contrast, for intubation, premedication rates differed according to previous successful laryngoscopy experience (p=0.01), but not according to operator status (p=0.21). Premedication regimens varied widely, the most common drug being propofol. Atropine was administered before 37/128 (29%) of non-life-threatening laryngoscopies, more frequently in combination with fentanyl ± muscle blocker than with propofol (p<0.001). A significant difference for non-premedication was found between NICUs with and without specific protocols (70 vs 24%; p<0.001 for intubation and 90 vs 53%; p=0.01 for LISA). Main reasons reported for the absence of premedication included perception of infant comfort (24 % of non-sedated laryngoscopies), lack of venous access (19%), unit protocol (16%) and personal habits (11%). In this exhaustive national cohort, substantial inter-center variability existed in premedication practices before laryngoscopy, with a persistently high proportion of laryngoscopies without life-threatening emergency performed without premedication, both for LISA and intubation. The development and implementation of premedication protocols may improve compliance and ultimately enhance the quality and safety of laryngoscopies.