Comparison of Sedation and Analgesia Requirements in Patients With SARS-CoV-2 Versus Non-SARS-CoV-2 Acute Respiratory Distress Syndrome on Veno-Venous ECMO

Abstract

Background: Increased analgosedation requirements have been described in patients with acute respiratory distress syndrome (ARDS) on extracorporeal membrane oxygenation (ECMO) support due to unique pharmacokinetic challenges. There is a paucity of data comparing sedation requirements in patients on ECMO for ARDS secondary to SARS-CoV-2 versus other etiologies of respiratory failure. Objective: To compare sedation and analgesia requirements in adult patients with SARS-CoV-2 versus non-SARS-CoV-2 ARDS requiring veno-venous (VV) ECMO support. Methods: We performed a retrospective cohort study of adult patients receiving sedation and analgesia on VV-ECMO support. Patients were excluded if cannulated at an outside hospital for greater than 24 hours, expired within 48 hours of ECMO cannulation, or received neuromuscular blocking agents for greater than 7 consecutive days following ECMO cannulation. Results: We evaluated 108 patients on VV-ECMO support, including 44 with non-SARS-CoV-2 ARDS and 64 with SARS-CoV-2 ARDS. The median daily dexmedetomidine requirements were significantly higher in the SARS-CoV-2 cohort (16.7 vs 13.4 mcg/kg/day, P = 0.03), while the median propofol daily requirements were significantly higher in the non-SARS-CoV-2 cohort (40.3 vs 53.5 mg/kg/day, P < 0.01). There was no difference in daily requirements of opioids, benzodiazepines, and ketamine between groups. Use of adjunct agents to facilitate weaning was significantly higher in the SARS-CoV-2 cohort (78.1% vs 43.2%, P < 0.01). Conclusion and Relevance: Patients with ARDS on VV-ECMO support require multiple analgosedative agents with concomitant use of nonparenteral adjunct agents. Further studies are needed to evaluate optimal analgosedation strategies in patients on ECMO support.

Characteristics of Delirium and Its Association with Sedation and In-Hospital Mortality in COVID-19 Patients on Veno-venous Extracorporeal Membrane Oxygenation

“…There is no standard analgosedation practice for COVID-19 patients on VV-ECMO. In a recent publication on COVID-19 patients on VV-ECMO for predominantly moderate to severe ARDS, higher doses of ketamine, benzodiazepine, propofol, and dexmedetomidine, and less use of opioids were noted over the rst seven days compared to ours over the full course of VV-ECMO therapy 29 . There is emerging evidence related to ECMO, such as the reduced dose of hydromorphone use due to its lower a nity to ECMO circuit compared to fentanyl 27,30 .…”

“…We performed exploratory, linear regression analysis between RASS scores and the daily median doses of commonly used medications while on VV-ECMO, and medications appear to have variable effects on sedation (Table S1). Further studies are needed to validate analgosedation strategies (i.e., an awake VV-ECMO strategy 31 , use of adjunct agents 29 , incorporating non-pharmacological interventions for delirium prevention 32 , patient-speci c factors to consider in ECMO 27,33 ) as well as implementation of novel, practical management approaches for the unstable patients (i.e., multimodal neuro-monitoring 24 , bedside brain MRI 34 ).…”

Characteristics of delirium and its association with sedation and in-hospital mortality in patients with COVID-19 on veno-venous extracorporeal membrane oxygenation

“…There is no standard analgosedation practice for patients with COVID-19 on VV-ECMO. In a recent publication on patients with COVID-19 receiving VV-ECMO for predominantly moderate to severe ARDS, higher doses of ketamine, benzodiazepine, propofol, and dexmedetomidine, and less use of opioids were noted over the first 7 days compared to ours over the full course of VV-ECMO therapy ( 29 ). There is emerging evidence related to ECMO, such as the reduced dose of hydromorphone use due to its lower affinity to the ECMO circuit compared to fentanyl ( 27 , 30 ).…”

“…We performed exploratory, linear regression analysis between RASS scores and the daily median doses of commonly used medications while on VV-ECMO, and medications appear to have variable effects on sedation ( Supplementary Table S1 ). Further studies are needed to validate analgosedation strategies [i.e., awake VV-ECMO strategy ( 31 ), use of adjunct agents ( 29 ), and patient-specific factors to consider in ECMO ( 27 , 32 )], as well as the implementation of novel, practical management approaches for the unstable patients [i.e., multimodal neuromonitoring ( 23 ) and bedside brain MRI ( 33 )].…”

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

“…In patients receiving ECMO for severe ARDS, several cohort studies have demonstrated a high sedative requirement to maintain the appropriate depth of sedation 11,12,16,17 . More recently, retrospective studies comparing patients receiving ECMO with and without severe coronavirus disease 2019 did not demonstrate differences in sedative requirements 18,19 . However, the generalizability of these studies is limited by differences in sedation goals and variation in providers' preference of agent and dosing.…”