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Bolesta S, Burry L, Perreault MM, Gélinas C, Smith KE, Eadie R, Carini FC, Saltarelli K, Mitchell J, Harpel J, Stewart R, Riker RR, Fraser GL, Erstad BL. International Analgesia and Sedation Weaning and Withdrawal Practices in Critically Ill Adults: The Adult Iatrogenic Withdrawal Study in the ICU. Crit Care Med 2023; 51:1502-1514. [PMID: 37283558 DOI: 10.1097/ccm.0000000000005951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Iatrogenic withdrawal syndrome (IWS) associated with opioid and sedative use for medical purposes has a reported high prevalence and associated morbidity. This study aimed to determine the prevalence, utilization, and characteristics of opioid and sedative weaning and IWS policies/protocols in the adult ICU population. DESIGN International, multicenter, observational, point prevalence study. SETTING Adult ICUs. PATIENTS All patients aged 18 years and older in the ICU on the date of data collection who received parenteral opioids or sedatives in the previous 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS ICUs selected 1 day for data collection between June 1 and September 30, 2021. Patient demographic data, opioid and sedative medication use, and weaning and IWS assessment data were collected for the previous 24 hours. The primary outcome was the proportion of patients weaned from opioids and sedatives using an institutional policy/protocol on the data collection day. There were 2,402 patients in 229 ICUs from 11 countries screened for opioid and sedative use; 1,506 (63%) patients received parenteral opioids, and/or sedatives in the previous 24 hours. There were 90 (39%) ICUs with a weaning policy/protocol which was used in 176 (12%) patients, and 23 (10%) ICUs with an IWS policy/protocol which was used in 9 (0.6%) patients. The weaning policy/protocol for 47 (52%) ICUs did not define when to initiate weaning, and the policy/protocol for 24 (27%) ICUs did not specify the degree of weaning. A weaning policy/protocol was used in 34% (176/521) and IWS policy/protocol in 9% (9/97) of patients admitted to an ICU with such a policy/protocol. Among 485 patients eligible for weaning policy/protocol utilization based on duration of opioid/sedative use initiation criterion within individual ICU policies/protocols 176 (36%) had it used, and among 54 patients on opioids and/or sedatives ≥ 72 hours, 9 (17%) had an IWS policy/protocol used by the data collection day. CONCLUSIONS This international observational study found that a small proportion of ICUs use policies/protocols for opioid and sedative weaning or IWS, and even when these policies/protocols are in place, they are implemented in a small percentage of patients.
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Affiliation(s)
- Scott Bolesta
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | - Lisa Burry
- Departments of Pharmacy and Medicine, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Marc M Perreault
- Department of Pharmacy, McGill University Health Center and Faculty of Pharmacy, University of Montréal, Montréal, QC, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, and Centre for Nursing Research/Lady Davis Institute, Jewish General Hospital-CIUSSS West-Central-Montréal, Montréal, QC, Canada
| | | | - Rebekah Eadie
- Critical Care/Pharmacy, Ulster Hospital, Dundonald, United Kingdom
| | - Federico C Carini
- MS-ICU, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Jamie Harpel
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | - Ryan Stewart
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | - Richard R Riker
- Department of Critical Care/Pulmonary Medicine, Maine Medical Center, Portland, ME
| | | | - Brian L Erstad
- Department of Pharmacy Practice and Science, The University of Arizona, Tucson, AZ
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Sigala MI, Dreucean D, Harris JE, Donahue KR, Bostan F, Voore P, Cuevas J, Morton C. Comparison of Sedation and Analgesia Requirements in Patients With SARS-CoV-2 Versus Non-SARS-CoV-2 Acute Respiratory Distress Syndrome on Veno-Venous ECMO. Ann Pharmacother 2023; 57:1005-1015. [PMID: 36639872 PMCID: PMC9841200 DOI: 10.1177/10600280221147695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Increased analgosedation requirements have been described in patients with acute respiratory distress syndrome (ARDS) on extracorporeal membrane oxygenation (ECMO) support due to unique pharmacokinetic challenges. There is a paucity of data comparing sedation requirements in patients on ECMO for ARDS secondary to SARS-CoV-2 versus other etiologies of respiratory failure. OBJECTIVE To compare sedation and analgesia requirements in adult patients with SARS-CoV-2 versus non-SARS-CoV-2 ARDS requiring veno-venous (VV) ECMO support. METHODS We performed a retrospective cohort study of adult patients receiving sedation and analgesia on VV-ECMO support. Patients were excluded if cannulated at an outside hospital for greater than 24 hours, expired within 48 hours of ECMO cannulation, or received neuromuscular blocking agents for greater than 7 consecutive days following ECMO cannulation. RESULTS We evaluated 108 patients on VV-ECMO support, including 44 with non-SARS-CoV-2 ARDS and 64 with SARS-CoV-2 ARDS. The median daily dexmedetomidine requirements were significantly higher in the SARS-CoV-2 cohort (16.7 vs 13.4 mcg/kg/day, P = 0.03), while the median propofol daily requirements were significantly higher in the non-SARS-CoV-2 cohort (40.3 vs 53.5 mg/kg/day, P < 0.01). There was no difference in daily requirements of opioids, benzodiazepines, and ketamine between groups. Use of adjunct agents to facilitate weaning was significantly higher in the SARS-CoV-2 cohort (78.1% vs 43.2%, P < 0.01). CONCLUSION AND RELEVANCE Patients with ARDS on VV-ECMO support require multiple analgosedative agents with concomitant use of nonparenteral adjunct agents. Further studies are needed to evaluate optimal analgosedation strategies in patients on ECMO support.
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Affiliation(s)
- Mariah I. Sigala
- Department of Pharmacy, Houston
Methodist Hospital, Houston, TX, USA
| | - Diane Dreucean
- Department of Pharmacy, Houston
Methodist Hospital, Houston, TX, USA
| | - Jesse E. Harris
- Department of Pharmacy, Houston
Methodist Hospital, Houston, TX, USA
| | - Kevin R. Donahue
- Department of Pharmacy, Houston
Methodist Hospital, Houston, TX, USA
| | - Fariedeh Bostan
- Department of Pharmacy, Houston
Methodist Hospital, Houston, TX, USA
| | - Prakruthi Voore
- Department of Pharmacy, Houston
Methodist Hospital, Houston, TX, USA
| | - Jose Cuevas
- Department of Pharmacy, Houston
Methodist Hospital, Houston, TX, USA
| | - Celia Morton
- Department of Pharmacy, Houston
Methodist Hospital, Houston, TX, USA
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Stallworth S, Ohman K, Schultheis J, Parish A, Erkanli A, Kim H, Rackley CR. Propofol-Associated Hypertriglyceridemia in Adults With Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:856-862. [PMID: 37172007 DOI: 10.1097/mat.0000000000001978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
The incidence and risk factors for propofol-associated hypertriglyceridemia (HTG) in patients receiving extracorporeal membrane oxygenation (ECMO) have not been evaluated. The purpose of this study was to determine the incidence and risk factors for propofol-associated HTG in patients with acute respiratory distress syndrome (ARDS) on ECMO. This retrospective, cohort study included 167 adults admitted to a medical intensive care unit (ICU) from July 1, 2013 to September 1, 2021, who received 24 hours of concurrent propofol and ECMO therapy. The primary outcome was the incidence of propofol-associated HTG. Secondary outcomes included HTG risk factors, time to development and resolution of HTG, and incidence of pancreatitis. HTG occurred in 58 (34.7%) patients. Patients with HTG had longer durations of ECMO (19 vs. 13 days, p < 0.001), longer ICU length of stay (26.5 vs. 23 days, p = 0.002), and higher in-hospital mortality (51.7 vs. 34.9%, p = 0.047). Baseline sequential organ failure assessment score was associated with an increased risk of developing HTG (hazard ratio [HR] = 1.19, 95% confidence interval [CI] = 1.09-1.30; p < 0.001). Propofol-associated HTG occurred in one-third of patients receiving ECMO for ARDS. Higher baseline illness severity and ECMO duration were associated with an increased risk of propofol-associated HTG.
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Affiliation(s)
| | - Kelsey Ohman
- From the Duke University Hospital, Durham, North Carolina
| | | | - Alice Parish
- From the Duke University Hospital, Durham, North Carolina
| | | | - Heewon Kim
- From the Duke University Hospital, Durham, North Carolina
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Skidmore KL, Rajabi A, Nguyen A, Imani F, Kaye AD. Veno-venous Extracorporeal Membrane Oxygenation: Anesthetic Considerations in Clinical Practice. Anesth Pain Med 2023; 13:e136524. [PMID: 38021335 PMCID: PMC10664155 DOI: 10.5812/aapm-136524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/28/2023] [Accepted: 06/04/2023] [Indexed: 12/01/2023] Open
Abstract
Context After the COVID-19 pandemic, multiple reviews have documented the success of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients who experience hypoxemia but have normal contractility may be switched to veno-venous-ECMO (VV-ECMO). Purpose In this review, we present three protocols for anesthesiologists. Firstly, transesophageal echocardiography (TEE) aids in cannulation and weaning off inotropes and fluids. Our main objective is to assist in patient selection for the Avalon Elite single catheter, which is inserted into the right internal jugular vein and terminates in the right atrium. Secondly, we propose appropriate anticoagulant doses. We outline day-to-day monitoring protocols to prevent heparin-induced thrombocytopenia (HIT) or resistance. Once the effects of neuromuscular paralysis subside, sedation should be reduced. Therefore, we describe techniques that may prevent delirium from progressing into permanent cognitive decline. Methods We conducted a PubMed search using the keywords VV-ECMO, TEE, Avalon Elite (Maquet, Germany), and quetiapine. We combined these findings with interviews conducted with nurses and anesthesiologists from two academic ECMO centers, focusing on anticoagulation and sedation. Results Our qualitative evidence synthesis reveals how TEE confirms cannulation while avoiding right atrial rupture or low flows. Additionally, we discovered that typically, after initial heparinization, activated partial thromboplastin time (PTT) is drawn every 1 to 2 hours or every 6 to 8 hours once stable. Daily thromboelastograms, along with platelet counts and antithrombin III levels, may detect HIT or resistance, respectively. These side effects can be prevented by discontinuing heparin on day two and initiating argatroban at a dose of 1 μg/kg/min while maintaining PTT between 61 - 80 seconds. The argatroban dose is adjusted by 10 - 20% if PTT is between 40 - 60 or 80 - 90 seconds. Perfusionists assist in establishing protocols following manufacturer guidelines. Lastly, we describe the replacement of narcotics and benzodiazepines with dexmedetomidine at a dose of 0.5 to 1 μg/kg/hour, limited by bradycardia, and the use of quetiapine starting at 25 mg per day and gradually increasing up to 200 mg twice a day, limited by prolonged QT interval. Conclusions The limitation of this review is that it necessarily covers a broad range of ECMO decisions faced by an anesthesiologist. However, its main advantage lies in the identification of straightforward argatroban protocols through interviews, as well as the discovery, via PubMed, of the usefulness of TEE in determining cannula position and contractility estimates for transitioning from VA-ECMO to VV-ECMO. Additionally, we emphasize the benefits in terms of morbidity and mortality of a seldom-discussed sedation supplement, quetiapine, to dexmedetomidine.
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Affiliation(s)
- Kimberly L. Skidmore
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Alireza Rajabi
- Department of Anesthesiology and Critical Care, Iran University of Medical Sciences, Tehran, Iran
| | - Angela Nguyen
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
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Martínez-Castro S, Monleón B, Puig J, Ferrer Gomez C, Quesada M, Pestaña D, Balvis A, Maseda E, de la Rica AS, Feijoo AM, Badenes R. Sedation with Sevoflurane versus Propofol in COVID-19 Patients with Acute Respiratory Distress Syndrome: Results from a Randomized Clinical Trial. J Pers Med 2023; 13:925. [PMID: 37373914 DOI: 10.3390/jpm13060925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) related to COVID-19 (coronavirus disease 2019) led to intensive care units (ICUs) collapse. Amalgams of sedative agents (including volatile anesthetics) were used due to the clinical shortage of intravenous drugs (mainly propofol and midazolam). METHODS A multicenter, randomized 1:1, controlled clinical trial was designed to compare sedation using propofol and sevoflurane in patients with ARDS associated with COVID-19 infection in terms of oxygenation and mortality. RESULTS Data from a total of 17 patients (10 in the propofol arm and 7 in the sevoflurane arm) showed a trend toward PaO2/FiO2 improvement and the sevoflurane arm's superiority in decreasing the likelihood of death (no statistical significance was found). CONCLUSIONS Intravenous agents are the most-used sedative agents in Spain, even though volatile anesthetics, such as sevoflurane and isoflurane, have shown beneficial effects in many clinical conditions. Growing evidence demonstrates the safety and potential benefits of using volatile anesthetics in critical situations.
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Affiliation(s)
- Sara Martínez-Castro
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Berta Monleón
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Jaume Puig
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - Carolina Ferrer Gomez
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - Marta Quesada
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario, 46014 Valencia, Spain
| | - David Pestaña
- Anesthesiology and Intensive Care Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Alberto Balvis
- Anesthesiology and Intensive Care Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Emilio Maseda
- Surgical Critical Care Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Alejandro Suárez de la Rica
- Anesthesiology and Surgical Critical Care Department, Hospital Universitario De La Princesa, 28006 Madrid, Spain
| | - Ana Monero Feijoo
- Surgical Critical Care Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Rafael Badenes
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
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Paparoupa M, Fischer M, Pinnschmidt HO, Grensemann J, Roedl K, Kluge S, Jarczak D. Impact of COVID-19 on Sedation Requirements during Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. J Clin Med 2023; 12:jcm12103515. [PMID: 37240620 DOI: 10.3390/jcm12103515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
COVID-19-associated ARDS (C-ARDS) is mentioned to express higher analgosedation needs, in comparison to ARDS of other etiologies. The objective of this monocentric retrospective cohort study was to compare the analgosedation needs between C-ARDS and non-COVID-19 ARDS (non-C-ARDS) on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Data were collected from the electronic medical records of all adult patients treated with C-ARDS in our Department of Intensive Care Medicine between March 2020 and April 2022. The control group included patients treated with non-C-ARDS between the years 2009 and 2020. A sedation sum score was created in order to describe the overall analgosedation needs. A total of 115 (31.5%) patients with C-ARDS and 250 (68.5%) with non-C-ARDS requiring VV-ECMO therapy were included in the study. The sedation sum score was significantly higher in the C-ARDS group (p < 0.001). COVID-19 was significantly associated with analgosedation in the univariable analysis. By contrast, the multivariable model did not show a significant association between COVID-19 and the sum score. The year of VV-ECMO support, BMI, SAPS II and prone positioning were significantly associated with sedation needs. The potential impact of COVID-19 remains unclear, and further studies are warranted in order to evaluate specific disease characteristics linked with analgesia and sedation.
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Affiliation(s)
- Maria Paparoupa
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Hans O Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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Kanji S, Williamson D, Hartwick M. Potential pharmacological confounders in the setting of death determined by neurologic criteria: a narrative review. Can J Anaesth 2023; 70:713-723. [PMID: 37131030 PMCID: PMC10202973 DOI: 10.1007/s12630-023-02415-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/11/2022] [Accepted: 10/18/2022] [Indexed: 05/04/2023] Open
Abstract
Guidelines for the determination of death by neurologic criteria (DNC) require an absence of confounding factors if clinical examination alone is to be used. Drugs that depress the central nervous system suppress neurologic responses and spontaneous breathing and must be excluded or reversed prior to proceeding. If these confounding factors cannot be eliminated, ancillary testing is required. These drugs may be present after being administered as part of the treatment of critically ill patients. While measurement of serum drug concentrations can help guide the timing of assessments for DNC, they are not always available or feasible. In this article, we review sedative and opioid drugs that may confound DNC, along with pharmacokinetic factors that govern the duration of drug action. Pharmacokinetic parameters including a context-sensitive half-life of sedatives and opioids are highly variable in critically ill patients because of the multitude of clinical variables and conditions that can affect drug distribution and clearance. Patient-, disease-, and treatment-related factors that influence the distribution and clearance of these drugs are discussed including end organ function, age, obesity, hyperdynamic states, augmented renal clearance, fluid balance, hypothermia, and the role of prolonged drug infusions in critically ill patients. In these contexts, it is often difficult to predict how long after drug discontinuation the confounding effects will take to dissipate. We propose a conservative framework for evaluating when or if DNC can be determined by clinical criteria alone. When pharmacologic confounders cannot be reversed, or doing so is not feasible, ancillary testing to confirm the absence of brain blood flow should be obtained.
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Affiliation(s)
- Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada.
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - David Williamson
- Faculté de pharmacie, Université de Montréal, Montreal, QC, Canada
- Pharmacy Department, Hôpital du Sacré-Cœur de Montréal and CIUSSS-Nord-de-l'ile-de-Montreal Research Center, Montreal, QC, Canada
| | - Michael Hartwick
- Department of Pharmacy, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, Canada
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Analgo-sedation strategies in patients with ECMO. Med Intensiva 2023; 47:165-169. [PMID: 36470736 DOI: 10.1016/j.medine.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 12/05/2022]
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9
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Romera-Ortega M, Chamorro-Jambrina C. Estrategias de analgosedación en pacientes con ECMO. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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10
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Yu X, Gu S, Li M, Zhan Q. Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Which Clinical Issues Should Be Taken Into Consideration. Front Med (Lausanne) 2021; 8:682526. [PMID: 34277659 PMCID: PMC8282255 DOI: 10.3389/fmed.2021.682526] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/01/2021] [Indexed: 01/18/2023] Open
Abstract
With the goal of protecting injured lungs and extrapulmonary organs, venovenous extracorporeal membrane oxygenation (VV-ECMO) has been increasingly adopted as a rescue therapy for patients with severe acute respiratory distress syndrome (ARDS) when conventional mechanical ventilation failed to provide effective oxygenation and decarbonation. In recent years, it has become a promising approach to respiratory support for awake, non-intubated, spontaneously breathing patients with respiratory failure, referred to as awake ECMO, to avoid possible detrimental effects associated with intubation, mechanical ventilation, and the adjunctive therapies. However, several complex clinical issues should be taken into consideration when initiating and implementing awake ECMO, such as selecting potential patients who appeared to benefit most; techniques to facilitating cannulation and maintain stable ECMO blood flow; approaches to manage pain, agitation, and delirium; and approaches to monitor and modulate respiratory drive. It is worth mentioning that there had also been some inherent disadvantages and limitations of awake ECMO compared to the conventional combination of ECMO and invasive mechanical ventilation. Here, we review the use of ECMO in awake, spontaneously breathing patients with severe ARDS, highlighting the issues involving bedside clinical practice, detailing some of the technical aspects, and summarizing the initial clinical experience gained over the past years.
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Affiliation(s)
- Xin Yu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Sichao Gu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Min Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
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