Sedation management in children supported on extracorporeal membrane oxygenation for acute respiratory failure

Objectives: To describe sedation management in children supported on extracorporeal membrane oxygenation for acute respiratory failure. Design: Secondary analysis of prospectively collected data from a multicenter randomized trial of sedation (Randomized Evaluation of Sedation Titration for Respiratory Failure). Setting: Twenty-one U.S. PICUs. Patients: One thousand two hundred fifty-five children, 2 weeks to 17 years old, with moderate/severe pediatric acute respiratory distress syndrome. Interventions: Sedation managed per usual care or Randomized Evaluation of Sedation Titration for Respiratory Failure protocol. Measurements and Main Results: Sixty-one Randomized Evaluation of Sedation Titration for Respiratory Failure patients (5%) with moderate/severe pediatric acute respiratory distress syndrome were supported on extracorporeal membrane oxygenation, including 29 managed per Randomized Evaluation of Sedation Titration for Respiratory Failure protocol. Most extracorporeal membrane oxygenation patients received neuromuscular blockade (46%) or were heavily sedated with State Behavioral Scale scores -3/-2 (34%) by extracorporeal membrane oxygenation day 3. Median opioid and benzodiazepine doses on the day of cannulation, 0.15 mg/kg/hr (3.7 mg/kg/d) and 0.11 mg/kg/hr (2.8 mg/kg/d), increased by 36% and 58%, respectively, by extracorporeal membrane oxygenation day 3. In the 41 patients successfully decannulated prior to study discharge, patients were receiving 0.40 mg/kg/hr opioids (9.7 mg/kg/d) and 0.39 mg/kg/hr benzodiazepines (9.4 mg/kg/d) at decannulation, an increase from cannulation of 108% and 192%, respectively (both p < 0.001). Extracorporeal membrane oxygenation patients experienced more clinically significant iatrogenic withdrawal than moderate/severe pediatric acute respiratory distress syndrome patients managed without extracorporeal membrane oxygenation support (p < 0.001). Compared to extracorporeal membrane oxygenation patients managed per Randomized Evaluation of Sedation Titration for Respiratory Failure protocol, usual care extracorporeal membrane oxygenation patients received more opioids during the study period (mean cumulative dose of 183.0 vs 89.8 mg/kg; p = 0.02), over 6.5 greater exposure days (p = 0.002) with no differences in wakefulness or agitation. Conclusions: In children, the initiation of extracorporeal membrane oxygenation support is associated with deep sedation, substantial sedative exposure, and increased frequency of iatrogenic withdrawal syndrome. A standardized, goal-directed, nurse-driven sedation protocol may help mitigate these effects.