University of Virginia Charlottesville, Virginia, United States
Abstract: Introduction/
Objective: In a randomized cohort of neonates undergoing cardiac surgery, we sought to determine whether nasal compared to oral intubation decreased analgesia and/or sedation administration. Our single center sedation practice during the study time frame of 2018 to 2021, was primarily opioid and dexmedetomidine infusions with additional doses of opioid and midazolam as needed based on SBS goals and nursing discretion.
Methods: This non-blinded, randomized control trial recruited neonates undergoing cardiac surgery (ClinicalTrials.gov NCT05378685). The subset of 46 subjects who had chest closure in the operating room are analyzed for this study. Total exposure to opioids (morphine or fentanyl), dexmedetomidine and midazolam in the cardiac intensive care unit (ICU) during the initial period intubated following surgery were quantified for each subject. Fentanyl doses were converted to morphine equivalents using the formula 1 mcg fentanyl = 0.1 mg morphine. Values for the 2 intubation routes were not normally distributed, so medians and interquartile ranges (IQR) are reported. Wilcoxon rank sum testing was performed.
Results: Subjects in the nasal and oral groups were similar in terms of pre-operative characteristics including gestational age at birth, birthweight, and rate of pre-operative intubation. Gestational age is statistically different, though this difference is not clinically significant; both groups have an IQR that is within term gestation. Surgical risk factors were also similar including STAT score, systemic to pulmonary shunt placement, aortic arch obstruction, cardiopulmonary bypass time, and aortic cross clamp time. (Table 1) The subjects were intubated and in the ICU for an equivalent amount of time, approaching 3 days. There was no difference in the total exposure or the per hour exposure for morphine or dexmedetomidine. (Table 2). Morphine was administered to 42 subjects and fentanyl to 4, two subjects in each group. Patients that received fentanyl had higher opioid exposure than those that received morphine. Midazolam exposure was higher in the orally intubated subjects, both the total and per hour exposure. Fifty percent of subjects, 23 patients, received midazolam bolus doses which were usually 0.05 mg/kg/dose. This was not statistically different based on intubation route, 60% of orally intubated subjects and 38% of nasally intubated subjects were exposed to midazolam in the ICU.
Conclusions: Intubation route, nasal or oral, does not impact opioid or dexmedetomidine exposure and minimally impacts midazolam exposure in the ICU for neonates recovering from congenital cardiac surgery.
