Ventilatory and Pharmacotherapeutic Strategies for Management of Adult Patients on Extracorporeal Life Support

Abstract

Extracorporeal life support (ECLS) can provide mechanical support for patients with severe life‐threatening cardiac or respiratory failure. ECLS is a complex therapy that has increased in use over several decades owing to advances in technology. In concert with this growth, there is an increased need to understand the complexity of this technology to augment the effectiveness of ECLS and minimize complications such as ventilator‐induced lung injury, bleeding, thrombosis, infections, and inadequate drug dosing. The purpose of this review was to discuss management strategies in adult patients receiving ECLS and provide recommendations on ventilator management, provision of adequate analgesia and sedation, treatment and prevention of infections, and anticoagulation.

ECLS-associated infections in adults: what we know and what we don’t yet know

“…Efforts to detect infections during ECLS come up against particular difficulties that could impede their prompt recognition and treatment, as well as the assessment of response to antimicrobial therapy. Passive or active cooling or heating of the blood as it passes through the membrane may mask fever or hypothermia [11]. The presence of infiltrates on chest radiographs, used to help identify VAP [31], may be difficult to interpret when extreme lung-protective ventilatory strategies are employed, as these result in extensive airspace opacification in the absence of a new infection [13], or in cases of severe cardiogenic pulmonary edema.…”

“…The pharmacokinetics and pharmacodynamics of antimicrobial agents used to treat infections during ECLS may be affected by several factors associated with both critical illness and the ECLS circuit itself, including clearance abnormalities in the setting of organ failures, potential for sequestration within the circuit, and increases in the volume of distribution (Vd) [10,11,47]. The lipophilicity and protein binding characteristics of a given drug play an important role in its interaction with the circuit [11]. Several antibiotics have been studied in the context of ECLS, and shown varying susceptibility to subtherapeutic levels due to sequestration or increased Vd; the results have been summarized elsewhere [10,11].…”

“…The lipophilicity and protein binding characteristics of a given drug play an important role in its interaction with the circuit [11]. Several antibiotics have been studied in the context of ECLS, and shown varying susceptibility to subtherapeutic levels due to sequestration or increased Vd; the results have been summarized elsewhere [10,11]. When available, therapeutic drug monitoring should be performed to ensure adequate dosing of medications during ECLS.…”

“…Furthermore, underlying comorbidities, critical illness, or perhaps even the extracorporeal circuit itself, may cause immune dysregulation, potentially leading to a higher rate of infectious complications. The management of infections during ECLS is made even more challenging by alterations in the pharmacokinetics and pharmacodynamics of antimicrobial agents in the presence of both critical illness and extracorporeal circuitry [10,11]. This narrative review aims to characterize the current understanding of infections associated with ECLS, discuss the challenges in identifying and treating these infections, and highlight areas where more data are needed to better understand the susceptibility to and impact of infections in patients managed with ECLS.…”

Prevention Strategies to Improve Outcomes in Critically Ill Adults

“…The uniqueness of these interventions mandates thoughtful consideration on how to optimize these therapies and prevent complications. One group highlighted optimal pharmacotherapeutic strategies for prevention of adverse events in patients receiving extracorporeal life support. Similarly, other reports discuss the application of newer anticonvulsants in the treatment of status epilepticus and neurovascular antiplatelet therapies in complex patients, respectively.…”