Clinical outcomes associated with sedation and analgesia in patients supported with venoarterial extracorporeal membrane oxygenation

Abstract

Sedatives and analgesics are frequently used in critically ill adult patients requiring mechanical ventilation in the intensive care unit, but optimal agent selection and dosing in patients supported with venoarterial extracorporeal membrane oxygenation remain poorly defined. This retrospective study evaluated whether sedative and analgesic agent selection and dosing had any impact on clinical outcomes after venoarterial extracorporeal membrane oxygenation decannulation. The primary endpoint of our study was the incidence of delirium within 48 h after venoarterial extracorporeal membrane oxygenation decannulation in patients who received an empiric ⩾50% sedation reduction of benzodiazepines (N = 22, group 2) compared to those who did not (N = 10, group 1) and those who required no sedatives within 24 h prior to venoarterial extracorporeal membrane oxygenation decannulation (N = 21, group 3). Secondary endpoints included time to extubation after decannulation, need for tracheostomy after decannulation, intensive care unit length of stay after decannulation, total hospital length of stay, and in-hospital mortality. Delirium within 48 h after decannulation was observed in 47% of all patients and did not differ between the three groups (50% vs 50% vs 43%, p = 0.9). No differences were observed in the secondary endpoints; though there was a trend toward shorter duration of mechanical ventilation and intensive care unit length of stay in patients who received an empiric ⩾50% sedation reduction. Our study suggests that we may need more than a 50% reduction in sedation but prospective studies with a larger sample size are warranted to evaluate how sedative/analgesic selection and dosing affect important clinical outcomes.

Analgosedation in Critically Ill Adults Receiving Extracorporeal Membrane Oxygenation Support

“…9,10 In addition, ECMO initiation and maintenance require adequate pain, agitation, and movement control to optimize ventilatory support and gas exchange in VV-ECMO, lower metabolic demand of VA-ECMO patients, and prevent potential harm. [11][12][13][14] Therefore, ECMO patients commonly receive higher doses of analgesic and sedative medications than patients with similar disease severity who are not receiving ECMO support. 15 Lack of evidence-based practice guidelines is more conspicuous during increased demand and medication shortage, as experienced in the ongoing COVID-19 pandemic.…”

Optimizing pharmacotherapy regimens in adult patients receiving extracorporeal membrane oxygenation: A narrative review for clinical pharmacists

“…In a small, retrospective study of patients receiving ECMO, delirium was reported in 47% of patients where 60% of the entire cohort were exposed to benzodiazepines. 24 Interestingly, rates of delirium were not different in patients that had a 50% or more reduction in their benzodiazepine requirements within 48 h of ECMO decannulation. Since many of these studies were retrospective, single center, and used institution-specific guidelines for sedation and analgesia, future research surrounding chemical and physiologic parameters that influence opioid and sedative clearance and the resultant long-term clinical outcomes associated with different practices are necessary.…”

“…The long‐term impact of high doses of opioids and sedatives in patients receiving ECMO is largely unknown. In a small, retrospective study of patients receiving ECMO, delirium was reported in 47% of patients where 60% of the entire cohort were exposed to benzodiazepines 24 . Interestingly, rates of delirium were not different in patients that had a 50% or more reduction in their benzodiazepine requirements within 48 h of ECMO decannulation.…”