Objective:

To evaluate opioid and benzodiazepine dose requirements in neonates and pediatric patients with ECMO support and identify factors associated with medication dose escalation.

Approach:

• Study Design: Retrospective cohort study of neonates and pediatric patients aged ≤14 years receiving ≥72 h of venoarterial ECMO support in a pediatric cardiac surgical intensive care unit from 2019 to 2023.
• Data Analysis: Opioid and benzodiazepine doses were converted to intravenous morphine and midazolam equivalents. Cumulative and average daily exposures were calculated, and multivariable regression analyses were performed to identify clinical predictors.

Key Findings:

• Eighty patients were included, with 68.8% having postoperative cardiac disease.
• All patients received opioids, and 96.3% received benzodiazepines; 66.3% received adjunctive sedative agents.
• Median cumulative opioid exposure was 7.33 mg/kg and benzodiazepine exposure was 15.75 mg/kg.
• Prolonged ICU length of stay and ECMO duration were associated with higher cumulative opioid exposure.
• Higher in-hospital mortality was linked to prolonged ICU stay, higher average opioid doses, acute kidney injury, and longer ECMO duration.

Interpretation:

Prolonged ICU stays and ECMO courses significantly increase cumulative opioid burdens, with specific predictors of in-hospital mortality identified.

Limitations:

• Retrospective study design may limit causal inferences.
• Exclusions of certain patient groups, such as those with neurological conditions requiring altered sedation strategies, may affect generalizability.

Conclusion:

Higher average opioid doses, acute kidney injury, and extended ICU and ECMO durations are key predictors of increased in-hospital mortality in this high-risk population.