Chapter 19 Medications

19.1 Sedatives:

  • Fentanyl: 2-8 mcg/kg/hr. Larger doses may be required due to drugs ability to adhere to ECMO circuit. If tachyphylaxis suspected, consider changing sedative to Morphine infusion.

  • Morphine: 10-20 mcg/kg/hr (have seen as high as 200 mcg/kg/hr upon tolerance)

  • Methadone: 0.05 to 0.1 mg/kg/dose q6 hrs. (may increase to 0.15 with tolerance)

  • Versed: 0.05 mg/kg/hr to 0.1mg/kg/hr

  • Vecuronium: 0.1mg/kg IV PRN, infusion: start 0.1mg/kg/hr

  • Nimbex (Cisatracurium): 2-4 mcg/kg/min IV infusion.

  • Precedex: 0.2 to 1 mcg/kg/hr

19.2 Pulmonary vasodilators:

  • iNO/O2:

  • Sildenafil drip

    • Retinal vascularization must be established before sildenafil is used in extremely preterm infants [1].
    • IV continuous: loading dose of 0.4 mg/kg over 3 hours, followed by a continuous infusion of 1.6 mg/kg/day (0.067 mg/kg/hour). These data are based on a dose-escalation trial (n=36) and not an efficacy trial [2].
    • IV Bolus: 0.5 mg/kg q6 hrs-( not sure source)
    • Oral: 0.5 to 1 mg/kg/dose orally 3 times daily [1]. Pharmacokinetics of sildenafil in neonates are highly variable [3]. Careful dose titration while monitoring oxygenation and blood pressure is required.

  • Flolan

    • IV: Starting dose 1-2 ng/kg/min, increase every 15 min by 1-2 ng/kg/min, wf hypotention stable dose is usually between 50 to 80 ng/kg/min
    • Inhalation (epoprostenol sodium-VELETRI) in pH 12 glycine diluent for flolan 50 ml inhalation solution: (glycine is an inherently viscous diluent, which leads the filter to become clogged)(Bhatt and Stein 2017): 12.5 ng/kg/min to 25 ng/kg/min or 50 ng/kg/min

  • Remodulin

    • IV: Initiate at 1 ng/kg/min. The dose will be increased in up to 2 ng/kg/min increments every 2 hrs until the OI is <10 (in the absence of dose-limiting side effects).(NCT02261883 2014)

  • Bosanten: 1mg/kg twice daily, Monitor LFTs.

  • Milrinone:

References

Bhatt, Amar M., and Erica J. Stein. 2017. “Clinical Complications with the Delivery of Inhaled Epoprostenol in the Operating Room.” Anesthesiology 127 (2): 383–83. https://doi.org/10.1097/ALN.0000000000001611.
NCT02261883. 2014. Remodulin as Add-on Therapy for the Treatment of Persistent Pulmonary Hypertension of the Newborn. ClinicalTrials.gov. https://www.clinicaltrials.gov/ct2/show/NCT02261883.