Effect of Extracorporeal Membrane Oxygenation Use on Sedative Requirements in Patients with Severe Acute Respiratory Distress Syndrome

Nigoghossian, Caroline Der; Dzierba, Amy; Etheridge, Joshua; Roberts, Russel J.; Muir, Justin; Brodie, Daniel; Schumaker, Greg; Bacchetta, Matthew; Ruthazer, Robin; Devlin, John W.

doi:10.1002/phar.1760

Cited by 40 publications

(61 citation statements)

References 36 publications

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“…The authors found that the maximum median 6‐hour sedative exposure was nearly twice as high in the ECMO group and was reached nearly 3 days later when compared to the group not receiving ECMO. However, there was no significant difference in 6‐hour sedative exposure in adjusted analyses [23]. Therefore, this study challenges whether the increased requirements of opioids and sedatives are a result of circuit‐related factors alone or whether other factors, such as tolerance, age or pharmacogenomics, play a central role.…”

Section: Analgesia and Sedationmentioning

confidence: 94%

“…The only comparative trial to date is a recent retrospective cohort study that enrolled consecutive adult patients with severe respiratory failure with ( n = 34) or without ( n = 60) venovenous ECMO support requiring at least one sedative to maintain a level of wakefulness appropriate to maintain patient comfort and safety while optimizing oxygenation and ventilator support [23]. The authors found that the maximum median 6‐hour sedative exposure was nearly twice as high in the ECMO group and was reached nearly 3 days later when compared to the group not receiving ECMO.…”

Section: Analgesia and Sedationmentioning

confidence: 99%

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Medicating patients during extracorporeal membrane oxygenation: the evidence is building

2017

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Section: Analgesia and Sedationmentioning

confidence: 94%

Section: Analgesia and Sedationmentioning

confidence: 99%

Medicating patients during extracorporeal membrane oxygenation: the evidence is building

2017

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“…Secondary outcomes included cumulative doses and duration of other analgesic and sedative agents used, proportion of patients receiving multiple sedative agents, daily RASS score, delirium‐coma‐free days, mechanical ventilation‐free days, ICU and hospital length of stay, and hospital mortality. In addition, total sedation dose during the first 7 days following DCL was compared by converting all sedatives to midazolam equivalents (5 mg/hr midazolam = 200 mg/hr propofol = 74.1 μg/hr dexmedetomidine) …”

Section: Methodsmentioning

confidence: 99%

Effect of Neuromuscular Blocking Agents on Sedation Requirements in Trauma Patients with an Open Abdomen

2019

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The appropriate level of sedation in patients with an open abdomen following damage control laparotomy (DCL) is debated. Chemical paralysis with neuromuscular blocking agents (NMBAs) has been used to decrease time to abdominal closure. We sought to evaluate the effect of NMBA use on sedation requirements in patients with an open abdomen and to determine the effect of sedation on patient outcomes. A retrospective cohort study was conducted at an American College of Surgeons’ verified level 1 trauma center. Adult trauma patients who underwent DCL between 2009 and 2015 were included. Patients with an intensive care unit length of stay of less than 48 hours and those who died before abdominal closure were excluded. The NMBA+ group received continuous NMBA within 24 hours of DCL; the NMBA− group did not. The primary outcome was cumulative sedation dose during the 7 days following DCL. Secondary outcomes included Richmond Agitation‐Sedation Scale (RASS) score, mechanical ventilation‐free days, and delirium‐coma‐free days. Delirium‐coma‐free days were analyzed with linear regression. A total of 222 patients were included (NMBA+ 125; NMBA− 97). Demographics were similar between groups including age, Injury Severity Score, and mechanism of injury. The median time to closure in the overall cohort was 2 days (interquartile range [IQR] 1–2 days). Propofol and fentanyl were the primary sedatives used. The NMBA+ group received higher cumulative doses of propofol (NMBA+ 5405 mg, IQR 3103–10,573 mg; NMBA− 3601 mg, IQR 1605–6887 mg; p=0.007), but not of fentanyl. Time to abdominal closure, but not NMBA use, was associated with a higher cumulative propofol dose on multivariate analysis. The NMBA+ group had significantly lower RASS scores on the first 3 days following DCL. Mechanical ventilation‐free days (NMBA+ 20 days vs NMBA− 18 days, p=0.960) and delirium‐coma‐free days (NMBA+ 18 days vs NMBA− 18 days, p=0.610) were similar between the groups. On linear regression, cumulative propofol dose was associated with fewer delirium‐coma‐free days (β‐coefficient −0.007, 95% confidence interval −0.015 to −0.003). In trauma patients managed with DCL, higher cumulative sedative doses were administered in patients who received adjunctive NMBA, although NMBA therapy was not associated with a higher cumulative propofol dose on multivariate analysis. Consideration must be given to the potential effect of sedation on delirium and awakening following DCL.

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“…For instance, compared to ARDS patients who do not receive ECMO, patients receiving ECMO may need higher sedation to tolerate the invasiveness of the procedure, to compensate for sedatives consumed by the ECMO circuit itself, 37 and because patients who receive ECMO tend to be younger and have higher illness severity. 38,39 Whether higher sedation is actually necessary for these patients is not known.…”

Section: Minimizing Sedationmentioning

confidence: 99%

Limiting sedation for patients with acute respiratory distress syndrome – time to wake up

Shah

Girard²,

Yende³

2017

Current Opinion in Critical Care

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Purpose of Review Critically ill patients with acute respiratory distress syndrome (ARDS) may require sedation in their clinical care. The goals of sedation in ARDS patients are to improve patient comfort and tolerance of supportive and therapeutic measures without contributing to adverse outcomes. This review discusses the current evidence for sedation management in patients with ARDS. Recent Findings Deep sedation strategies should be avoided in the care of patients with ARDS because deep sedation has been associated with increased time on mechanical ventilation, longer ICU and hospital length of stay, and higher mortality in critically ill patients. Adoption of protocol-based, light-sedation strategies are preferred and improve patient outcomes. Although the optimal sedative agent for ARDS patients is unclear, benzodiazepines should be avoided due to associations with oversedation, delirium, prolonged intensive care unit and hospital length of stay, and increased mortality. Minimizing sedation in patients with ARDS facilitates early mobilization and early discharge from the intensive care unit, potentially aiding in recovery from critical illness. Strategies to optimize ventilation in ARDS patients, such as low-tidal volume ventilation and high positive end-expiratory pressure (PEEP) can be employed without deep sedation; however, deep sedation is required if patients receive neuromuscular blockade, which may benefit some ARDS patients. Knowledge gaps persist as to whether or not prone positioning and extracorporeal membrane oxygenation (ECMO) can be tolerated with light sedation. Summary Current evidence supports the use of protocol-based, light-sedation strategies in critically ill patients with ARDS. Further research into sedation management specifically in ARDS populations is needed.

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Effect of Extracorporeal Membrane Oxygenation Use on Sedative Requirements in Patients with Severe Acute Respiratory Distress Syndrome

Cited by 40 publications

References 36 publications

Medicating patients during extracorporeal membrane oxygenation: the evidence is building

Medicating patients during extracorporeal membrane oxygenation: the evidence is building

Effect of Neuromuscular Blocking Agents on Sedation Requirements in Trauma Patients with an Open Abdomen

Limiting sedation for patients with acute respiratory distress syndrome – time to wake up

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