Sedation and analgesia during ECMO

Sedation and analgesia during ECMO (M Raes)

ELSO guidelines suggest moderate to heavy sedation in the first 24 hours

“Awake” extracorporeal membrane oxygenation (ECMO): pathophysiology, technical considerations, and clinical pioneering

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

Medicating patients during extracorporeal membrane oxygenation: the evidence is building

Volatile sedation in the intensive care unit A systematic review and meta-analysis

Inhalative sedation with small tidal volumes under venovenous ECMO.

CONCLUSION

1. Do we need to sedate our ECMO patient?

• Not all patients
• Perhaps ‘less’ is ‘more’
• Major clinical challenge (especially in VV-ECMO)
• Scarce data

2. What is the best sedation strategy?

• No consensus
• Sequestration on ECMO needs higher doses in most drugs
• Inhaled anesthetics promising alternative?

3. Should we monitor?

• YES!

Weaning from ECMO (D dos Reis Miranda)

VV-ECMO

When to do wean trial?

• FiO2 < 60%
• Vt 4-6 ml/kg
• Driving pressure < 15 mbar
• PEEP < 15 mbar

VA-ECMO

Decrease blood flow

• Approx. 1 l/min for LV failure
• Approx. 0.5 l/min for RV failure

Functional evaluation of sublingual microcirculation indicates successful weaning from VA-ECMO in cardiogenic shock.

CONCLUSION

VV ECMO

• Do not decrease ECMO blood flow
• Set ECMO gasflow off at reasonable vent setting
• Maintain this for couple of hours (practical: overnight)

VA ECMO

• Do not decrease ECMO gasflow
• Set reasonable vent setting
• Decrease ECMObloodflow to 0.5 – 1.0 liter/min for 5-15 min
• Do not solely rely on macrohemodynamic parameters
• Use echo or microcirculation