Sedation and analgesia requirements during venovenous extracorporeal membrane oxygenation in acute respiratory distress syndrome patients

Abstract

Introduction: The purpose of this study is to describe sedation and analgesia management, and identify the factors associated with increased demand for medication in acute respiratory distress syndrome (ARDS) patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO). Methods: This retrospective, single-center study included consecutive adult ARDS patients who received VV-ECMO for at least 24 hours from January 2018 to December 2020 in a comprehensive intensive care unit. The electronic medical records were retrospectively reviewed to collect data. Results: Forty-two adult patients meeting the inclusion criteria were included in the study. Midazolam, sufentanil, and remifentanil were main sedatives and analgesics used in the patient population. The morphine equivalents, representative of the demand for opioids, was 512.9 (IQR, 294.5, 798.2) mg/day. The midazolam equivalents, representative of benzodiazepine requirement, was 279.6 (IQR, 208.8, 384.5) mg/day. The levels of serum creatinine, total bilirubin, lactic acid, SOFA score, and APACHE Ⅱ score at cannulation were found to be associated with opiate or benzodiazepine requirements. Multiple linear regression analysis revealed a linear correlation between midazolam equivalents and morphine equivalents (p < 0.001). In addition, there was a negative linear correlation between Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score and midazolam equivalents (p = 0.024). Conclusions: The sedation and analgesia requirements of ARDS patients receiving VV-ECMO often increase simultaneously. More large-scale studies are needed to confirm the risk factors for increased sedation and analgesia needs in patients supported on VV-ECMO.

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.…”

“…Opioid and benzodiazepine requirements at VV-ECMO initiation in patients with ARDS may be associated with serum creatinine, total bilirubin, lactate, and severity of illness (SOFA and APACHE II scores). 17 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.…”

“…Propofol, midazolam, and dexmedetomidine are prone to significant circuit sequestration because of their lipophilicity and high protein binding; therefore, higher than recommended doses may be necessary to achieve adequate sedation. 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 .…”

“…The intersection between nonpharmacologic factors that may influence analgesic and sedative response in a critically ill patient (e.g., body weight, chronic pain, drug tolerance, diminished organ function) with known changes in pharmacokinetic changes of opioids and sedatives as a result of the ECMO circuit should be considered when crafting individualized analgesic and sedation plans (Table 1 4,5,22,23 ). Opioid and benzodiazepine requirements at VV‐ECMO initiation in patients with ARDS may be associated with serum creatinine, total bilirubin, lactate, and severity of illness (SOFA and APACHE II scores) 17 . The long‐term impact of high doses of opioids and sedatives in patients receiving ECMO is largely unknown.…”

Association of analgosedation with psychiatric symptoms and health-related quality of life in ARDS survivors: Post hoc analyses of the DACAPO study

“…Ketamine was administered in nearly one third of the patients. In a recent study by Ren and colleagues, all 42 patients with ARDS who received venovenous extracorporeal membrane oxygenation were given midazolam combined with sufentanil or remifentanil; in 69%, analgosedation was supplemented with propofol and in 25% with dexmedetomidine [21].…”