Remifentanil: Drug of Choice for Intubation in Neonates?

Background: Endotracheal intubation is a painful and stressful procedure for neonates, often triggering adverse physiological responses. In 2010, the American Academy of Pediatrics (AAP) recommended premedication for elective intubation in neonates to reduce pain and stress and to increase the chances of success. In recent years, several drugs have emerged as a treatment option to improve comfort and safety of neonates undergoing endotracheal intubation. Worldwide, a range of agents are used. As remifentanil is a short-acting analgesic with sedative effects, it may be a suitable option. Therefore, we evaluated the available evidence regarding benefits and side effects for this drug. Methods: In this narrative review, we describe the benefits and risks of remifentanil as drug of choice for neonatal intubation. Results: Literature search demonstrates a relatively limited number of randomized trials, indicating that current practice is informed by a combination of small clinical trials, observational studies, and pharmacological research. Owing to its unique pharmacokinetic profile, remifentanil is an effective agent in the neonatal population allowing the provision of intense analgesia with a rapid recovery profile and has a good clinical applicability in situations where early extubation of patients is desired following the end of the opioid infusion. Reported side effects include respiratory depression, apnea, bradycardia, and chest wall rigidity, similar to other opioids. Chest wall rigidity appears to be strongly influenced by dosing strategies and the speed of intravenous administration. Conclusions: Remifentanil's unique properties make it a promising option for neonatal intubation. However vigilance and close monitoring is required. Further research is warranted to compare remifentanil with other opioids that have a near similar pharmacological profile (e.g., fentanyl analogues).