Medication Complications in Extracorporeal Membrane Oxygenation

Shah, Ami G.; Peahota, Michelle M.; Thoma, Brandi; Kraft, Walter K.

doi:10.1016/j.ccc.2017.06.010

Cited by 12 publications

(10 citation statements)

References 94 publications

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“…2,3 Research into sedation for patients on ECMO is extremely limited, with practice extrapolated from sedation practice in the general intensive care unit (ICU) as well as basic pharmacokinetics. 4–6 Consequently, there are currently no evidence-based guidelines for sedation management in the ECMO patient cohort. 7,8 The sedation management of medical and surgical critically ill patients has evolved to the current approach of sedation minimisation through the use of daily sedation interruption or targeting light sedation with the aim of enabling early mobilisation.…”

Section: Introductionmentioning

confidence: 99%

Sedation with alfentanil versus fentanyl in patients receiving extracorporeal membrane oxygenation: outcomes from a single-centre retrospective study

et al. 2019

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Introduction: In November 2016, our institution switched from alfentanil to fentanyl for analgesia and sedation in adult patients receiving extracorporeal membrane oxygenation. There is no published evidence comparing the use of alfentanil with fentanyl for sedation in extracorporeal membrane oxygenation patients. We conducted a retrospective observational study to explore any significant differences in patient outcomes or in the prescribing of adjunct sedatives before and after the switch. Methods: Patients were retrospectively identified from a prospectively recorded database of all patients who received extracorporeal membrane oxygenation at our institution between January 2016 and October 2017. Patients included those sedated with alfentanil or fentanyl. The total daily doses of intravenous opioids (alfentanil or fentanyl) were calculated for each patient, and the prescribing of adjunctive sedative or analgesic agents was recorded. Patient demographics, extracorporeal membrane oxygenation modality, clinical outcomes including mortality and length of intensive care and hospital stay were recorded. Results: A total of 174 patients were identified, 69 on alfentanil and 95 on fentanyl. There was no difference found between groups for mode of extracorporeal membrane oxygenation, age, Acute Physiology and Chronic Health Evaluation 2 score (APACHE II) and Charlson score, except for body mass index (p = 0.002). No differences in patient outcomes was observed between groups, although patients in the alfentanil group received a significantly higher median total daily dose of adjuvant sedatives (quetiapine (p = 0.016) and midazolam (p = 0.009)). Conclusions: No differences in patient outcomes were found between extracorporeal membrane oxygenation patients sedated with alfentanil compared with fentanyl. There was a statistically significant reduction in some adjunctive sedatives in patients managed with a fentanyl-based regimen. Prospective studies are required to confirm these results.

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Section: Introductionmentioning

confidence: 99%

Sedation with alfentanil versus fentanyl in patients receiving extracorporeal membrane oxygenation: outcomes from a single-centre retrospective study

et al. 2019

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“…( 6 , 7 ) Generally, the volume of distribution (Vd) increases and drug clearance (CL) and elimination decrease during ECMO, but in patients with systemic inflammatory response syndrome/sepsis, or because of drug sequestration by the circuit, clearance is increased. ( 8 ) The optimization of antimicrobial doses by means of dose titration and the determination of plasma levels according to PK/pharmacodynamic changes may improve the survival and clinical evolution of critically ill patients. ( 6 ) The initiation of ECMO yields a series of important PK changes that are described below.…”

Section: Introductionmentioning

confidence: 99%

“…Hemodilution, the priming of tubing, drug sequestration, organ failure and the hydrophilicity of the drug increase Vd. ( 7 , 8 ) Moreover, drug sequestration takes place at the oxygenation membrane level and in the rest of the system, depending on lipophilicity, ionization, plasma protein binding and the drug’s molecular size, ( 7 ) with greater sequestration of lipophilic and highly protein-bound drugs. ( 7 , 9 ) Decreased plasma protein binding increases the unbound drug concentration, resulting in an increased Vd, especially for highly protein-bound drugs.…”

Section: Introductionmentioning

confidence: 99%

“…Drug metabolism can be altered in ECMO patients because the acute reduction in hepatic blood flow and the alteration of hepatic enzyme function in ECMO reduces clearance of hepatically cleared medications. ( 7 - 8 ) . ( ) The majority of PK studies in ECMO have been performed in newborns, and sedatives, analgesics and antimicrobials are the best-studied drugs.…”

Section: Introductionmentioning

confidence: 99%

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Pharmacokinetics of micafungin in patients treated with extracorporeal membrane oxygenation: an observational prospective study

López-Sánchez¹,

Moreno-Puigdollers

Rubio-Lopez³

et al. 2020

Revista Brasileira De Terapia Intensiva

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Objective To determine micafungin plasma levels and pharmacokinetic behavior in patients treated with extracorporeal membrane oxygenation. Methods The samples were taken through an access point before and after the membrane in two tertiary hospitals in Spain. The times for the calculation of pharmacokinetic curves were before the administration of the drug and 1, 3, 5, 8, 18 and 24 hours after the beginning of the infusion on days one and four. The area under the curve, drug clearance, volume of distribution and plasma half-life time with a noncompartmental pharmacokinetic data analysis were calculated. Results The pharmacokinetics of the values analyzed on the first and fourth day of treatment did not show any concentration difference between the samples taken before the membrane (Cin) and those taken after the membrane (Cout), and the pharmacokinetic behavior was similar with different organ failures. The area under the curve (AUC) before the membrane on day 1 was 62.1 (95%CI 52.8 - 73.4) and the AUC after the membrane on this day was 63.4 (95%CI 52.4 - 76.7), p = 0.625. The AUC before the membrane on day 4 was 102.4 (95%CI 84.7 - 142.8) and the AUC was 100.9 (95%CI 78.2 - 138.8), p = 0.843. Conclusion The pharmacokinetic parameters of micafungin were not significantly altered.

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“…2 At the University of Pennsylvania, the use of intravenous anesthesia is more common than volatile anesthetics in this situation. There are gaps in understanding of drug pharmacokinetics in the presence of an ECMO circuit, 7 making the ideal anesthetic while on ECMO uncertain. Likewise, Fierro and colleagues' paper demonstrated considerable variation in management of the ventilator during surgery, potentially contributing to more than half of patients experiencing an undesirable increase in peak airway pressures intraoperatively.…”

mentioning

confidence: 99%