Analgesic |
Fentanyl | IV or IM:b 1–4 mcg/kg | IV, almost immediate; IM, 7–15 minutes | IV, 30–60 minutes; IM,1–2 hours | Apnea, hypotension, CNS depression, chest wall rigidity | Preferred analgesic Effects reversible with naloxone Give slowly (preferably over 3–5 minutes, at least over 1–2 minutes) to avoid chest wall rigidity Chest wall rigidity can be treated with naloxone and muscle relaxants |
Remifentanil | IV:1–3 mcg/kg; may repeat in 2–3 minutes if needed | IV, almost immediate | IV, 3–10 minutes | Apnea, hypotension, CNS depression, chest wall rigidity | Acceptable analgesic Short duration of action and limited experience in neonates Effects reversible with naloxone Give slowly over 1–2 minutes to avoid chest wall rigidity Chest wall rigidity can be treated with naloxone and muscle relaxants |
Morphine | IV or IM: 0.05–0.1 mg/kg | IV, 5–15 minutes; IM, 10–30 minutes | IV, 3–5 hours; IM, 3–5 hours | Apnea, hypotension, CNS depression | Acceptable analgesic agent Use only if other opioids are not available; if selected, must wait at least 5 minutes for onset of action Effects reversible with naloxone |
Hypnotic/sedative |
Midazolam | IV or IM: 0.05–0.1 mg/kg | IV, 1–5 minutes; IM, within 5–15 minutes | IV, 20–30 minutes; IM, 1–6 hours | Apnea, hypotension, CNS depression | Acceptable sedative for use in term infants in combination with analgesic agents Hypotension more likely when used in combination with fentanyl Not recommended in premature infants Effects reversible with flumazenil |
Thiopental | IV: 3–4 mg/kg | IV, 30–60 seconds | IV, 5–30 minutes | Histamine release, apnea, hypotension, bronchospasm | Acceptable hypnotic agent Hypotension more likely when used in combination with fentanyl and/or midazolam |
Propofol | IV: 2.5 mg/kg | Within 30 seconds | 3–10 minutes | Histamine release, apnea, hypotension, bronchospasm, bradycardia; often causes pain at injection site | Acceptable hypnotic agent Limited experience in newborns Neonatal dosing has not been well established |
Muscle relaxant |
Pancuronium | IV: 0.05–0.10 mg/kg | 1–3 minutes | 40–60 minutes | Mild histamine release, hypotension, tachycardia, bronchospasm, excessive salivation | Acceptable muscle relaxant Relatively longer duration of action Effects reversible with atropine and neostigmine |
Vecuronium | IV: 0.1 mg/kg | 2–3 minutes | 30–40 minutes | Mild histamine release, hypertension/hypotension, tachycardia, arrhythmias, bronchospasm | Preferred muscle relaxant Effects reversible with atropine and neostigmine |
Rocuronium | IV: 0.6–1.2 mg/kg | 1–2 minutes | 20–30 minutes | Mild histamine release, hypertension/hypotension, tachycardia, arrhythmias, bronchospasm | Preferred muscle relaxant Effects reversible with atropine and neostigmine |
Succinylcholine | IV: 1–2 mg/ kg; IM:b 2 mg/kg | IV, 30–60 seconds; IM, 2–3 minutes | IV, 4–6 minutes; IM, 10–30 minutes | Hypertension/hypotension, tachycardia, arrhythmias, bronchospasm, hyperkalemia, myoglobinemia, malignant hyperthermia | Acceptable muscle relaxant Contraindicated in presence of hyperkalemia and family history of malignant hyperthermia |
Vagolytic |
Atropine | IV or IM: 0.02 mg/kg | 1–2 minutes | 0.5–2 hours | Tachycardia, dry hot skin | Preferred vagolytic agent |
Glycopyrrolate | IV: 4–10 mcg/kg | 1–10 minutes | ∼6 hours | Tachycardia, arrhythmias, bronchospasm | Acceptable vagolytic agent Limited experience in newborns Contains benzyl alcohol as preservative |