Pentobarbital for Sedation during Mechanical Ventilation in the Pediatric ICU Patient

In most pediatric intensive care units (PICUs), sedation is provided using opioids and benzodiazepines, either alone or in combination. While these agents are effective in most patients, certain situations may arise in which this usual combination is ineffective. There are no large series outlining the use of pentobarbital for sedation in the PICU population. The current report is a retrospective review of the use of pentobarbital for sedation of 50 patients in the PICU and provides information concerning the use of phenobarbital to prevent withdrawal symptoms following the prolonged administration of pentobarbital. The 50 patients ranged in age from 1 month to 14 years and in weight from 3.1 to 56 kg. All required sedation during mechanical ventilation. Prior to changing to pentobarbital, sedation was inadequate despite midazolam doses of ≥0.4 mg/kg/hr, fentanyl doses of ≥10 μg/kg/hr, and morphine doses of ≥100 μg/kg/hr. The duration of pentobarbital infusion ranged from 2 to 37 days (median 4 days) in doses ranging from 1 to 6 mg/kg/hr (median 2 mg/kg/hr). Twelve patients also received an ongoing opioid infusion for more than 48 hours after starting the pentobarbital infusion to control pain related to a surgical procedure or an acute medical illness. There was an increase in pentobarbital infusion requirements over time. In the 14 patients that received pentobarbital for 5 days or more, the requirements increased from 1.2 ± 0.4 mg/kg/hr on day 1 to 3.4 ± 0.7 mg/kg/hr on day 5 ( p < 0.01). Pentobarbital was effective in all 50 patients without significant adverse effects.