Hi everybody.

Which drugs/ doses/ rotation of sedatives do you use in extremely preterm infants on prolonged mechanical ventilation. We commonly use non-pharmacological strategies, fentanyl and dexmedetomidine, but after 1-2 weeks, they trend to tolerate them and need a progressive increase... We're managing now a 24weeker on HFOV wiht a severe pulmonary emphysema (after RDS and pulmonary hemorrhage on firts days), The weaning is not possible, and she is needing high doses of fentanyl and dexmedetomidine + extra bolus of fentanyl.

Would anybody use benzodiacepines? Or rotate to morphine sulfate?

In extreme small preterms we don't use any sedatives only for the ventilation. We adjust the mechanical ventilation that the baby is comfortable.

We use sedatives only if the babies have severe ventilation issues (dyspnea) or painful procedures.

Tricky situation. A low dose of clonidine, as an adjunkt to opiods may help. But keep an eye on blood pressure!

although we use the optimal ventilation strategy, sometimese the baby is agitated or fthe pain score is high. We usually start on dexmedetomidin but if he is still agitated may use midazolam also.

We use morphine and fentanyl. When NOWS occur or are suspected, we add clonidine. We usually avoid midazolam, as it may cause seizure-like episodes, which may trigger septic workups, unnecessary investigations like EEG, etc.

In our Warsaw NICU we would use dexmedetomidine in a dose of 0,7 to 1,0 mcg/kg/hour in cases of difficulty in synchronising the baby with ventilator, in extere cases we use opioids (morphine or sufentanil).

Tkanks and good luck

We don't use benzodiacepines in preterm babies. We rotate to morphine sulfate+ extra dose of skin to skin contact (if parents are available)

This cases are very difficult to manage.... Good luck!

De rutina no utilizamos sedación en microprematuros ventilados. Si ante dificultad respiratoria grave o causa que producen dolor, morfina o fentanilo, asociamos dexmedetomidina. Dosis bajas el menor tiempo posible. Si es mas de 72 horas, vamos descendiendo lentamente para no producir sindrome de abstinencia. No utilizamos midazolam en prematuros por los efectos encefalicos