Plasma fentanyl levels in infants undergoing extracorporeal membrane oxygenation

Leuschen, M. Patricia; Willett, Lynne D.; Hoie, Eric B.; Bolam, David Lloyd; Bussey, M. E.; Goodrich, Paul; Zach, Terence L.; Nelson, Robert M.

doi:10.1016/s0022-5223(19)34161-3

Cited by 32 publications

(12 citation statements)

References 16 publications

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“…Clearance of morphine and its metabolites was reduced in several studies and correlated with severity of illness [29][30][31] . Variable data exists regarding the PK of morphine and fentanyl in neonates receiving ECMO 32,33 .…”

Section: Discussionmentioning

confidence: 99%

Increased Sedation Requirements in Patients Receiving Extracorporeal Membrane Oxygenation for Respiratory and Cardiorespiratory Failure

Shekar

Roberts

Mullany

et al. 2012

Anaesth Intensive Care

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Critically ill patients receiving extracorporeal membrane oxygenation (ECMO) are often noted to have increased sedation requirements. However, data related to sedation in this complex group of patients is limited. The aim of our study was to characterise the sedation requirements in adult patients receiving ECMO for cardiorespiratory failure. A retrospective chart review was performed to collect sedation data for 30 consecutive patients who received venovenous or venoarterial ECMO between April 2009 and March 2011. To test for a difference in doses over time we used a regression model. The dose of midazolam received on ECMO support increased by an average of 18 mg per day (95% confidence interval 8, 29 mg, P=0.001), while the dose of morphine increased by 29 mg per day (95% confidence interval 4, 53 mg, P=0.021) The venovenous group received a daily midazolam dose that was 157 mg higher than the venoarterial group (95% confidence interval 53, 261 mg, P=0.005). We did not observe any significant increase in fentanyl doses over time (95% confidence interval 1269, 4337 μg, P=0.94). There is a significant increase in dose requirement for morphine and midazolam during ECMO. Patients on venovenous ECMO received higher sedative doses as compared to patients on venoarterial ECMO. Future research should focus on mechanisms behind these changes and also identify drugs that are most suitable for sedation during ECMO.

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Section: Discussionmentioning

confidence: 99%

Increased Sedation Requirements in Patients Receiving Extracorporeal Membrane Oxygenation for Respiratory and Cardiorespiratory Failure

Shekar

Roberts

Mullany

et al. 2012

Anaesth Intensive Care

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“…However, in studies in neonates receiving continuous i.v. fentanyl for analgesia during the treatment by extracorporeal membrane oxygenation (ECMO), a rapid development of tolerance was observed (Arnold et al, 1990;1991;Leuschen et al, 1993). In both studies, neonates needed steadily increasing infusion rates of fentanyl and required more supplemental analgesia and sedative drugs to reach an adequate effect.…”

Section: Discussionmentioning

confidence: 99%

Inefficacy of high‐dose transdermal fentanyl in a patient with neuropathic pain a case report

Bleeker

Bremer

Dongelmans

et al. 2001

European Journal of Pain

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Pain partially responsive to opioids can lead to rapid escalating dosages due to tolerance development. In this report the case of a 58-year-old female with neuropathic pain using increasing transdermal (TTS) fentanyl dosages to a maximum dose of 3400 microg/h resulting in fentanyl plasma levels of 173 ng/ml is described. For pain relief an epidural infusion at the level T1-2 with bupivacaine was started. Immediate pain relief was accompanied by short lasting respiratory depression and drowsiness.

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“…Earlier in the course of extracorporeal support, patients on ECMO usually require deep sedation and paralysis to optimise circuit flows and ventilation whilst eliminating pain, anxiety and other forms of distress induced by the ICU environment (71). Further to this, emerging reports have documented greater sedative requirements are needed for critically ill neonates (33,59,72,73) and adults during ECMO support (5,6). PK studies in neonates have consistently reported increased V d and decreased drug CL during ECMO (16,35), both of which could potentially explain the heightened sedation requirement observed in this patient cohort.…”

Section: Antifungalsmentioning

confidence: 99%

Optimising drug dosing in patients receiving extracorporeal membrane oxygenation

et al. 2018

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Optimal pharmacological management during extracorporeal membrane oxygenation (ECMO) involves more than administering drugs to reverse underlying disease. ECMO is a complex therapy that should be administered in a goal-directed manner to achieve therapeutic endpoints that allow reversal of disease and ECMO wean, minimisation of complications (treatment of complications when they do occur), early interruption of sedation and rehabilitation, maximising patient comfort and minimising risks of delirium. ECMO can alter both the pharmacokinetics (PK) and pharmacodynamics (PD) of administered drugs and our understanding of these alterations is still evolving. Based on available data it appears that modern ECMO circuitry probably has a less significant impact on PK when compared with critical illness itself. However, these findings need further confirmation in clinical population PK studies and such studies are underway. The altered PD associated with ECMO is less understood and more research is indicated. Until robust dosing guidelines become available, clinicians will have to rely on the principles of drug dosing in critically ill and known PK alterations induced by ECMO itself. This article summarises the PK alterations and makes preliminary recommendations on possible dosing approaches.

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Plasma fentanyl levels in infants undergoing extracorporeal membrane oxygenation

Cited by 32 publications

References 16 publications

Increased Sedation Requirements in Patients Receiving Extracorporeal Membrane Oxygenation for Respiratory and Cardiorespiratory Failure

Increased Sedation Requirements in Patients Receiving Extracorporeal Membrane Oxygenation for Respiratory and Cardiorespiratory Failure

Inefficacy of high‐dose transdermal fentanyl in a patient with neuropathic pain a case report

Optimising drug dosing in patients receiving extracorporeal membrane oxygenation

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