Endotracheal Intubation Procedure Note (Neonate)

Procedure: Endotracheal Intubation

Date/Time of Procedure: [date and time] (If exact time unavailable, provide best estimate labeled as approximate with brief reason.)

Location: [delivery room / NICU / ED / OR / transport / other]

Gestational Age at Birth: [weeks+days]   Postnatal Age (DOL): [days of life]

Weight (kg): [value] [measured / estimated] (If estimated, note source.)

Primary Operator: [name, credentials, role]   Supervising Clinician: [name, credentials] (Include if applicable.)

Urgency: [elective / urgent / emergent / periresuscitation]

Indication

[Primary clinical indication, immediate goal, and any anticipated airway difficulty] (Examples of indications: respiratory failure, apnea/bradycardia, surfactant administration, airway protection. Note anatomic concerns or prior failed attempts if present.)

Consent

[Consent status and details] (State one of: consent obtained, not obtained due to emergency, not applicable, or unknown if performed prior to arrival. If obtained, specify who consented, method, interpreter use if applicable, and that risks/benefits/alternatives were discussed. Never leave blank or ambiguous.)

Time-Out

[Time-out performed: yes / no] (If yes, note participants and confirm patient identity, procedure, and equipment were verified. If no, state reason. A single attestation sentence is sufficient.)

Pre-Procedure Assessment

• Baseline vitals immediately prior to first attempt: HR [bpm], SpO₂ [%], respiratory support [device and FiO₂] (If unobtainable due to emergent circumstances, state explicitly.)
• Monitoring in place: [continuous pulse oximetry / ECG / noninvasive blood pressure / capnography]
• Airway assessment: [anticipated difficulty, anatomic concerns, secretions/blood/meconium if present]
• Preoxygenation strategy: [method, device, FiO₂, duration]

Premedication

• [Medication name, dose per kg, route, time, observed effect or adverse response]
• [Additional medications as applicable]

(If no premedication given, explicitly state reason such as emergent intubation during resuscitation. Do not omit this section.)

Equipment and Approach

• Route: [oral / nasal]
• Laryngoscopy: [direct / video]   Blade: [type and size]
• ETT: [internal diameter mm], [cuffed / uncuffed]; stylet [used / not used]
• Adjuncts: [external laryngeal manipulation / bougie / none / other]

Attempt Log

(Document each intubation attempt. Do not omit failed attempts. If duration or physiologic nadirs were not recorded, write "not recorded.")

• Attempt [number]:
  • Operator/role: [name, role]
  • Device/technique: [direct/video; blade type/size; adjuncts]
  • Outcome: [successful / esophageal placement / aborted / unable to pass tube]
  • Duration: [seconds or "not recorded"]
  • Physiologic tolerance: SpO₂ nadir [%], HR nadir [bpm]
  • Corrective actions: [ventilation provided, repositioning, equipment change, operator change] (Include for unsuccessful attempts.)
• Attempt [number]: [Repeat fields as above for each additional attempt]

Summary: Total attempts: [number]. Successful on attempt: [number]. Escalation to more experienced operator: [yes / no] (If yes, specify who.)

Tube Placement

• Final ETT: [internal diameter mm], [cuffed / uncuffed]
• Insertion depth: [cm at lip / nares] (If adjusted after imaging, document initial depth, adjustment, and final secured depth.)
• Securing method: [ETT holder / tape / other]

Confirmation of Placement

• Direct visualization of tube passing vocal cords: [yes / no]
• Bilateral chest rise: [present / absent]
• Auscultation: [bilateral breath sounds present, no epigastric sounds / findings]
• Exhaled CO₂: [colorimetric / waveform], result: [positive / negative / equivocal] (If negative or equivocal, document interpretation and alternate confirmation.)
• Physiologic response: [improvement in HR and/or SpO₂ / no change / deterioration]
• Chest radiograph: [obtained / pending / not obtained]; ETT tip position: [cm above carina / at carina / in right mainstem]

Complications

[None / Complications encountered] (If complications occurred, document each with severity, duration, and management. Include hypoxemia with SpO₂ nadir and duration, bradycardia with HR nadir and interventions, esophageal or mainstem intubation, airway trauma or bleeding, pneumothorax, or medication-related adverse effects as applicable.)

Post-Procedure Status and Plan

• Immediate post-intubation vitals: HR [bpm], SpO₂ [%], overall stability [stable / unstable]
• Ventilation: [mode and key settings] (Or reference ventilator flowsheet.)
• Ongoing management: [sedation/analgesia plan, timing of follow-up blood gas, additional monitoring]
• Family communication: [family updated: yes / no / pending; by whom]

Attestation

[Attestation statement] (If trainee performed the procedure under supervision, specify who performed and who supervised, and whether supervisor was present for key portions. If performed independently by an attending, state that or omit this section.)