INTRODUCTION: Patients supported with extracorporeal membrane oxygenation (ECMO) frequently require prolonged, high-intensity analgosedation because of neuromuscular blockade, pain related to procedures, and pharmacokinetic alterations. These exposures increase the risk of iatrogenic medication toxicity and withdrawal. OBJECTIVES: We evaluated whether buprenorphine (BUP) use during ECMO reduced full agonist opioid exposure and improved sedation compared with matched comparators. METHODS: Using a retrospective matched case-control cohort design among ECMO patients in a cardiovascular intensive care unit, we contrasted 30 patients treated with BUP versus 30 comparator patients not treated with BUP (NO-BUP) matched using an a priori deterministic hierarchy. Comparisons were anchored to two matched time points: (i) the day before BUP exposure and (ii) the day after attaining the full therapeutic BUP dose; NO-BUP comparators were assessed on the analogous ECMO days. The primary outcome was the between-group difference in change in daily intravenous morphine milligram equivalents (MME) across this time period. RESULTS: Each cohort included 27 venovenous and three venoarterial ECMO patients. Demographics and illness severity did not differ between groups. Groups significantly differed in MME change scores (p < 0.001) with the BUP cohort decreasing significantly (p < 0.001) from 184.1 (interquartile range IQR 70.2-367.2) to 0.0 (IQR 0.0-11.6) median MME whereas NO-BUP comparators nonsignificantly decreased (p = 0.517) from 230.8 (IQR 153.3-567.0) to 177.2 (IQR 85.3-663.1). Groups also differed (p = 0.031) in time in target RASS range (-2 to 0); the BUP cohort significantly improved from 53.9% to 91.2% (p < 0.001) whereas NO-BUP comparators nominally improved from 37.8% to 46.1% (p = 0.275). In the BUP cohort, there was no precipitated withdrawal, opioid-induced constipation, or respiratory depression. Rates of tracheostomy, mortality, and extubation before decannulation did not differ significantly. CONCLUSION: BUP initiation among ECMO patients was feasible and associated with a marked reduction in full agonist opioid exposure and improved light-sedation target attainment. These findings are hypothesis-generating given the retrospective design and potential residual confounding.
Carroll et al. (Wed,) studied this question.
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