Phenobarbital as a Sedation Strategy to Reduce Opioid and Benzodiazepine Burden in Neonatal Extracorporeal Membrane Oxygenation.

Objective: The study aims to describe our experience with the implementation of phenobarbital as a primary sedation strategy during neonatal extracorporeal membrane oxygenation (ECMO).

Study Design: Retrospective chart review in a level IV neonatal intensive care unit between 2011 and 2021 comparing neonatal ECMO patients before and after the implementation of a sedation-analgesia (SA) protocol using scheduled phenobarbital as the primary sedative. Groups were compared for neonatal and ECMO characteristics, cumulative SA doses, and in-hospital outcomes. Comparison between groups was performed using Mann-Whitney test on continuous variables and chi-square on nominal variables.

Results: Forty-two patients were included, 23 preprotocol and 19 postprotocol. Birth, pre-ECMO, and ECMO clinical characteristics were similar between groups except for a lower birth weight in the postprotocol group ( = 0.024). After standardization of phenobarbital SA protocol, there was a statistically significant reduction in median total morphine dose (31.38-17.65 mg/kg,  = 0.006) and median total midazolam dose (36.21-6.36 mg/kg,  < 0.001). There was also a reduction in median total days on morphine by 7.5 days ( = 0.026) and midazolam by 6.6 days ( = 0.003). There were no differences in ECMO duration or in-hospital outcomes between groups.

Conclusion: In this cohort, short-term use of phenobarbital as primary sedation strategy during neonatal ECMO was associated with reduced opioid and midazolam burden. Such reduction, however, did not affect in-hospital outcomes.

Key Points: · Prolonged sedation on ECMO puts infants at risk for iatrogenic withdrawal.. · Phenobarbital is a feasible sedation strategy for ECMO.. · Phenobarbital sedation strategy may mitigate risk by decreasing opioid and midazolam burden..