Peri-procedural Events in Neonates with Retinopathy of Prematurity Requiring Laser Photocoagulation in a Level IV NICU

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Background: Laser photocoagulation is standard of care for treatment of threshold retinopathy of prematurity (ROP), and procedural respiratory support is commonly achieved using endotracheal intubation and mechanical ventilation. There is no consensus on pain and airway management during laser treatment for ROP. Neonates are especially sensitive to many drugs including anesthetic agents, placing them at risk of life-threatening systemic complications and lingering respiratory depression.

Objective: To describe the peri-procedural events of infants requiring laser photocoagulation for ROP.

Design/Methods: Retrospective chart review of neonates requiring ROP exam between 1/2017 and 8/2020 at an academic level IV referral NICU. Baseline maternal and neonatal characteristics, ROP exam findings and ophthalmologic interventions were collected. Among those requiring laser treatment, cardiorespiratory index (CRI) scores, pain scores, need for intubation, and duration of respiratory support were obtained. Descriptive analysis and group comparisons were performed using Statistical Package for Social Sciences (SPSS) software.

Results:200 patients were included (Figure 1). Neonatal and maternal characteristics comparing laser and non-laser groups are depicted in Table 1. Twenty-eight patients (14%) received laser treatment; one was performed prior to admission. Eighty-two percent (22/27) required re-intubation with atropine, fentanyl and vecuronium, 3 were already intubated, and 1 had non-invasive ventilation with sedation. The mean NPASS pain scores after laser were Day 0: 0.038, Day 1: 0.096 and Day 2: 0.12. The mean CRI scores on Day 0-2 were all 1 (no change from baseline). 

Of the infants that required intubation, 36% had >1 intubation and 16% had >1 extubation attempt. The average duration of intubation following laser was 2.48 days, with 40% needing steroids and 16% racemic epinephrine to facilitate extubation. The mean total respiratory support time was 9 days post-laser photocoagulation.

Conclusions: Nearly all infants undergoing laser photocoagulation for ROP required rapid sequence intubation and continued respiratory support for an average of 9 days post-procedure. Intubation in this high-risk population led to steroid exposure in 40% of the patients in order to facilitate extubation. All had minimal peri-procedural pain and stable CRI scores. Next steps include a quality initiative to implement a moderate sedation protocol during laser treatment in an effort to reduce the need for intubation and associated complications.

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St. Christopher's Hospital for Children
Drexel University School of Medicine
Drexel University College of Medicine/ St Christopher's Hospital for Children , Philadelphia
Drexel University College of Medicine/St Christopher's Hospital for Children

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