Institutional Variation in Fentanyl Use for Children on Extracorporeal Membrane Oxygenation

OBJECTIVE Fentanyl is an opioid analgesic commonly used for pain management in children who are critically ill. However, fentanyl use is discouraged during extracorporeal membrane oxygenation (ECMO) because of its lipophilic and protein-binding properties. These properties have been shown to increase the risk of opioid withdrawal and other poor health outcomes. Our objectives were to evaluate institutional variation and the factors associated with fentanyl use for children on ECMO. PATIENTS AND METHODS This retrospective study included children aged less than 18 years who received ECMO between 2016 to 2023 at children’s hospitals in the Pediatric Health Information System. Multivariable hierarchical logistic regression evaluated factors associated with fentanyl prescribing during ECMO. RESULTS Overall, 7731 children (54.5% male, 53.8% white, 48.6% neonatal) were included, with 91.9% receiving fentanyl during ECMO. Significant institutional variability was observed, with percent days of fentanyl use during ECMO ranging from 13.4% to 100%. Overall, 20.3% of the total variation in fentanyl use on ECMO was attributable to differences among hospitals. On multivariable regression, compared with adolescents, neonates (odds ratio OR, 2.35; 95% CI, 1.61–3.43) had the highest likelihood of receiving fentanyl. Additionally, children with cardiovascular disease (OR, 1.63; 95% CI, 1.35–1.95) had an increased likelihood of receiving fentanyl, and children with a history of prematurity (OR, 0.50; 95% CI, 0.38–0.66) had a decreased likelihood. CONCLUSION Despite its known risks, fentanyl remains widely used for children on ECMO. Additionally, significant institutional variation exists, with neonates having the highest risk of fentanyl exposure. Our findings underscore the need for enhanced guidelines for sedation and pain management for children receiving ECMO.