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Individualizing and Minimizing Sedation on Venovenous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome Patients, a Reply

deBacker, Julian; Fan, Eddy; Mehta, Sangeeta

doi: 10.1097/MAT.0000000000000970
Letters to the Editor
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SDC

Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada

Department of Medicine and Interdepartmental Division of Critical Care Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada

Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada

Disclosure: The authors have no conflicts of interest to report.

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To the Editor:

We thank Shekar et al.1–3 for their interest in our study; and commend them for their important research regarding the pharmacokinetic and pharmacodynamic changes induced by the extracorporeal membrane oxygenation (ECMO) circuit.

Our observational study of patients managed in an experienced ECMO center illustrated wide variability in sedation depth, from deeply sedated to awake and interactive. Although sedation depth is obviously dependent on patient and clinician factors, it appears possible for patients to be awake, comfortable, interactive, and mobilizing during ECMO.

In non-ECMO patients, light sedation confers advantages such as patient inter-activeness and active mobilization, and has been shown to improve outcomes in critically ill patients.4–7 Keeping patients awake also promotes an individualized patient-centered approach, whereby patients can communicate their symptoms and receive the appropriate pharmacologic and nonpharmacologic interventions for pain, anxiety, and insomnia.

In patients on ECMO, we agree that the benefits of light sedation must be weighed against the safety risks, including hemodynamic, respiratory, and device-removal concerns. It should be noted that the few patients who could sit, stand, or walk with the ECMO circuit did so safely, with continuous monitoring and the support of multiple personnel. Serious complications (such as decannulation) in our cohort were absent. Given the safety concerns, we recommend a cautious approach, with gradual lightening of the patient’s sedation to evaluate her tolerance.

There are no prospective trials evaluating dexmedetomidine in patients on ECMO; data in non-ECMO patients does not show advantages compared with conventional sedatives, and the cost is prohibitive in many centers.

We agree with the comments by Shekar et al.1–3 regarding early tracheostomy, the use of adjunctive enteral medications, and the need for prospective studies evaluating light sedation in this population.

Julian deBacker

Cleveland Clinic Lerner College of Medicine

Cleveland, Ohio

Department of Medicine and Interdepartmental Division of Critical Care Medicine

Mount Sinai Hospital

Toronto, Ontario, Canada

Eddy Fan

Department of Medicine and Interdepartmental Division of Critical Care Medicine

University Health Network and University of Toronto

Toronto, Ontario, Canada

Sangeeta Mehta

Department of Medicine and Interdepartmental Division of Critical Care Medicine

Mount Sinai Hospital and University of Toronto

Toronto, Ontario, Canada

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References

1. Shekar K, Roberts JA, Mcdonald CI, et al. Sequestration of drugs in the circuit may lead to therapeutic failure during extracorporeal membrane oxygenation. Crit Care Lond Engl 2012.16: R194.
2. Shekar K, Roberts JA, Mullany DV, et al. Increased sedation requirements in patients receiving extracorporeal membrane oxygenation for respiratory and cardiorespiratory failure. Anaesth Intensive Care 2012.40: 648–655.
3. Shekar K, Fraser JF, Smith MT, et al. Pharmacokinetic changes in patients receiving extracorporeal membrane oxygenation. J Crit Care 2012.27: 741.e9–741.e18.
4. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000.342: 1471–1477.
5. Shehabi Y, Chan L, Kadiman S, et al. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: A prospective longitudinal multicentre cohort study. Intensive Care Med 2013.39: 910–918.
6. Balzer F, Weiß B, Kumpf O, et al. Early deep sedation is associated with decreased in-hospital and two-year follow-up survival. Crit Care Lond Engl 2015.19: 197.
7. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013.41: 263–306.
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