Subtherapeutic Pentobarbital Levels in a Patient With Intracranial Pressure Crisis on Venoarterial Extracorporeal Membrane Oxygenation.

Elevations in intracranial pressure (ICP) may result after neurologic injury. As ICP increases, cerebral perfusion pressure (CPP) decreases and may lead to further neurologic damage. Management of an ICP crisis may involve several different therapies, including hyperosmolar therapy, cerebrospinal fluid diversion, or surgical craniectomy. Pentobarbital is a barbiturate that has been shown to decrease cerebral blood flow and may be used in severe cases of ICP crisis. The literature has not described management strategies for ICP crisis in patients requiring extracorporeal membrane oxygenation (ECMO). Highly lipophilic medications with increased protein binding may be sequestered within the ECMO circuit. Pentobarbital is lipophilic (Log P = 2.1) and highly protein bound (45-70%). We describe a case of a patient on venoarterial (VA) ECMO with ICP crisis managed with pentobarbital with subtherapeutic pentobarbital levels.