Sedation practices in adult patients with severe ARDS on extracorporeal respiratory support using VV ECMO – An international survey

Introduction: Optimal sedation strategies for patients with respiratory failure requiring venovenous extracorporeal membrane oxygenation (VV ECMO) are not well defined. Methods: Physicians caring for patients on ECMO in an intensive care unit were invited to complete an international survey about sedation and analgesia practices for adult patients undergoing VV ECMO for severe Acute Respiratory Distress Syndrome (ARDS). Results: The survey was completed by 234 physicians, most commonly identifying as critical care (29.9%) and practicing in North America (38.9%). The Richmond Agitation Sedation Scale (88.5%) and Clinical Pain Observation Tool (40.2%) were commonly used for monitoring. Agents of choice were propofol (73.9% prior to ECMO and 56% within 48 h after initiation) and fentanyl (57.3% and 40.2%), with increasing preference for dexmedetomidine after ECMO initiation (14.5% prior to and 25.6% after initiation). Routine neuromuscular blockade use beyond 48 h after cannulation was rare (1.3%). Common strategies to reduce sedatives included sweep gas titration (74.4%) and minimizing nocturnal interventions (63.7%). Most respondents believe antipsychotics also work to this effect (57.3%). Conclusions: Sedation strategies for adult ARDS patients receiving VV ECMO seem to be influenced by time from cannulation and patient factors. Future research should focus on identifying optimal sedation strategies and developing a consensus for best practice.