Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation

Dzierba, Amy; Abrams, Darryl; Madahar, Purnema; Muir, Justin; Agerstrand, Cara; Brodie, Daniel

doi:10.1016/j.jcrc.2019.05.014

Cited by 21 publications

(25 citation statements)

References 41 publications

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“…A recent international survey of ECMO centers demonstrated that fentanyl is the most commonly preferred analgesic with 77% of centers using it as first line 25 . Only 16% of ECMO centers reported hydromorphone as the analgesic of choice.…”

Section: Discussionmentioning

confidence: 99%

Comparison of Hydromorphone versus Fentanyl‐based Sedation in Extracorporeal Membrane Oxygenation: A Propensity‐Matched Analysis

et al. 2020

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INTRODUCTION Data comparing sedatives in patients receiving extracorporeal membrane oxygenation (ECMO) are sparse. However, it is known that the ECMO circuit alters the pharmacokinetic properties of medications via drug sequestration of lipophilic agents and increased volume of distribution. OBJECTIVES This study evaluated the difference in days alive without delirium or coma and the sedative requirements in patients receiving fentanyl versus hydromorphone in ECMO patients. METHODS This single-center retrospective observational study evaluated adults receiving ECMO for more than 48 hours and continuous infusion of either fentanyl or hydromorphone for at least 6 hours. Of 148 patients evaluated, 88 received fentanyl and 60 received hydromorphone continuous infusion sedation. Outcomes included delirium-free and coma-free (DFCF) days, narcotic use, and sedative use. MAIN RESULTS There was an increase in the number of DFCF days in the hydromorphone group at day 7 (p=0.07) and day 14 (p=0.08) and a significant reduction in daily fentanyl equivalent exposure. Propensity score matching yielded 54 matched pairs. An 11.1% increase was observed in the proportion of ECMO days alive without delirium or coma in the hydromorphone group at 7 days (53.2% vs 42.1%, p=0.006). Patients in the hydromorphone group received significantly fewer narcotics with a median of 555 µg (interquartile range [IQR] 287-905 µg) of fentanyl equivalents per day compared with 2291 µg (IQR 1053-4023 µg) in the fentanyl group (p<0.005). CONCLUSION The use of hydromorphone-based sedation in ECMO patients resulted in more days alive without delirium or coma while significantly reducing narcotic requirements. KEY WORDS acute respiratory distress syndrome, extracorporeal membrane oxygenation, intensive care, sedation, delirium.

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Section: Discussionmentioning

confidence: 99%

Comparison of Hydromorphone versus Fentanyl‐based Sedation in Extracorporeal Membrane Oxygenation: A Propensity‐Matched Analysis

et al. 2020

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“…22 A recent international, cross-sectional survey reported that deep sedation was targeted for 64% of critically ill patients who received venovenous ECMO therapy in the first 24 h after initiation of therapy. 23 Second, we used registered ICD-10 codes to extract the delirium diagnoses from the NHIS database. Since only definite diagnoses of delirium are registered in the database, there may be additional cases of delirium that were not registered as they were not definite diagnoses.…”

Section: Discussionmentioning

confidence: 99%

Delirium and Long-Term Outcomes among Survivors of Extracorporeal Membrane Oxygenation Therapy: A Nationwide Cohort Study in South Korea

Park

Song

2021

J Intensive Care Med

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Background: The prevalence of delirium and its association with long-term outcomes of extracorporeal membrane oxygenation (ECMO) therapy have not yet been identified. We aimed to investigate the prevalence of delirium and its associated factors during hospitalization among ECMO survivors. We also examined whether the occurrence of delirium was associated with 1-year all-cause mortality among ECMO survivors. Methods: As a population-based cohort study, data were obtained from the National Health Insurance Service database in South Korea. Adults older than 18 years who received ECMO therapy between 2005 and 2018 were included in this study. ECMO survivors were defined as patients who were discharged from the hospital. Results: The analysis included a total of 8153 ECMO survivors, of whom 551 (6.8%) experienced delirium during hospitalization. Older age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: 1.00-1.02; P = 0.004), male sex (OR: 1.38, 95% CI: 1.13-1.68; P = 0.002), underlying depression (OR: 1.90, 95% CI: 1.49-2.41; P < 0.001), and longer length of hospital stay (OR: 1.02, 95% CI: 1.02-1.03; P < 0.001) were associated with a higher incidence of delirium. In multivariable Cox regression modeling, the occurrence of delirium was not significantly associated with the risk of 1-year all-cause mortality (hazard ratio: 0.90, 95% CI: 0.76-1.07; P = 0.229). Conclusion: The prevalence of delirium among ECMO survivors during hospitalization was 6.8% in South Korea, and old age, male sex, longer duration of hospital stay, and underlying depression were associated with it. However, there was no significant association between delirium and 1-year all-cause mortality among ECMO survivors.

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“…Parenteral opioids such as fentanyl and morphine/hydromorphone have often been chosen as the preferred agents in ECMO, and hydromorphone showed less sequestration in ECMO circuits and more days alive without delirium ( 77 ). Compared with propofol or benzodiazepines, dexmedetomidine produces sedative effects without amnesia or respiratory depression, making it an attractive option for general sedation in ARDS patients undergoing awake ECMO ( 78 ). Other adjunct agents like atypical antipsychotics have also been used in ARDS patients, but the safety and efficacy in awake ECMO need to be proven.…”

Section: Sedation and Analgesiamentioning

confidence: 99%

Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Which Clinical Issues Should Be Taken Into Consideration

et al. 2021

Front. Med.

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With the goal of protecting injured lungs and extrapulmonary organs, venovenous extracorporeal membrane oxygenation (VV-ECMO) has been increasingly adopted as a rescue therapy for patients with severe acute respiratory distress syndrome (ARDS) when conventional mechanical ventilation failed to provide effective oxygenation and decarbonation. In recent years, it has become a promising approach to respiratory support for awake, non-intubated, spontaneously breathing patients with respiratory failure, referred to as awake ECMO, to avoid possible detrimental effects associated with intubation, mechanical ventilation, and the adjunctive therapies. However, several complex clinical issues should be taken into consideration when initiating and implementing awake ECMO, such as selecting potential patients who appeared to benefit most; techniques to facilitating cannulation and maintain stable ECMO blood flow; approaches to manage pain, agitation, and delirium; and approaches to monitor and modulate respiratory drive. It is worth mentioning that there had also been some inherent disadvantages and limitations of awake ECMO compared to the conventional combination of ECMO and invasive mechanical ventilation. Here, we review the use of ECMO in awake, spontaneously breathing patients with severe ARDS, highlighting the issues involving bedside clinical practice, detailing some of the technical aspects, and summarizing the initial clinical experience gained over the past years.

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Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation

Cited by 21 publications

References 41 publications

Comparison of Hydromorphone versus Fentanyl‐based Sedation in Extracorporeal Membrane Oxygenation: A Propensity‐Matched Analysis

Comparison of Hydromorphone versus Fentanyl‐based Sedation in Extracorporeal Membrane Oxygenation: A Propensity‐Matched Analysis

Delirium and Long-Term Outcomes among Survivors of Extracorporeal Membrane Oxygenation Therapy: A Nationwide Cohort Study in South Korea

Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Which Clinical Issues Should Be Taken Into Consideration

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