OBJECTIVES With the expanding use of extracorporeal membrane oxygenation (ECMO), understanding drug pharmacokinetics has become increasingly important, particularly in pediatric patients. This ex vivo study examines the effect of a pediatric Quadrox-iD ECMO circuit on the sequestration and binding of mycophenolate mofetil (MMF), tacrolimus, and hydromorphone hydrochloride, which have not been extensively studied to date in pediatric ECMO circuits. Fentanyl, which has been well studied, was used as a comparator.
METHODS ECMO circuits were set up using Quadrox-iD pediatric oxygenators and centrifugal pumps. The circuit was primed with whole blood and a reservoir was attached to represent a 5-kg patient. Fourteen French venous and 12 French arterial ECMO cannulas were inserted into the sealed reservoir. Temperature, pH, PO2, and PCO2 were monitored and corrected. MMF, tacrolimus, hydromorphone, and fentanyl were injected into the ECMO circuit. Serial blood samples were taken from a postoxygenator site at intervals over 12 hours, and levels were measured.
RESULTS Hydromorphone hydrochloride was not as significantly sequestered by the ex vivo pediatric ECMO circuit when compared with fentanyl. Both mycophenolic acid and tacrolimus serum concentrations were stable in the circuit over 12 hours.
CONCLUSIONS Hydromorphone may represent a useful medication for pain control for pediatric patients on ECMO due to its minimal sequestration. Mycophenolic acid and tacrolimus also did not show significant sequestration in the circuit, which was unexpected given their lipophilicity and protein-binding characteristics, but may provide insight into unexplored pharmacokinetics of particular medications in ECMO circuits.
How to use this card set:1. Recognize or anticipate resource shortfall. 2. Implement appropriate incident management system and plans; assign subject matter experts (technical specialists) to problem.3. Determine degree of shortfall, expected demand, and duration; assess ability to obtain needed resources via local, regional, or national vendors or partners. 4. Find category of resource on index. 5. Refer to specific recommendations on card. 6. Decide which strategies to implement and/or develop additional strategies appropriate for the facility and situation. 7. Assure consistent regional approach by informing public health authorities and other facilities if contingency or crisis strategies will continue beyond 24h and no regional options exist for re-supply or patient transfer; activate regional scarce resource coordination plans as appropriate. 8. Review strategies every operational period or as availability (supply/demand) changes.
Core strategies to be employed (generally in order of preference) during, or in anticipation of a scarce resource situation are:Prepare -pre-event actions taken to minimize resource scarcity (e.g., stockpiling of medications). Substitute -use an essentially equivalent device, drug, or personnel for one that would usually be available (e.g., morphine for fentanyl). Adapt -use a device, drug, or personnel that are not equivalent but that will provide sufficient care (e.g., anesthesia machine for mechanical ventilation). Conserve -use less of a resource by lowering dosage or changing utilization practices (e.g., minimizing use of oxygen driven nebulizers to conserve oxygen).Re-use -re-use (after appropriate disinfection/sterilization) items that would normally be single-use items.Re-allocate -restrict or prioritize use of resources to those patients with a better prognosis or greater need.
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