Characterization of Analgesia and Sedation Practice in ExtraCorporeal Membrane Oxygenation treated patients with Acute Respiratory Distress Syndrome (CASPER): a retrospective study
CCCF ePoster library. deBacker J. Nov 1, 2016; 150941; 62
Julian deBacker
Julian deBacker
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Topic: Retrospective or Prospective Cohort Study

Characterization of Analgesia and Sedation Practice in ExtraCorporeal Membrane Oxygenation treated patients with Acute Respiratory Distress Syndrome (CASPER): a retrospective study


Julian DeBacker1,2 MSc, Erik Tamberg2 BSc, Eduardo Mireles-Cabodevila1 MD, Amy Nowacki PhD1, Laveena Munshi2,4 MD, Lisa Burry2,4 PharmD, Eddy Fan3,4 MD, PhD, Sangeeta Mehta2,4 MD, FRCPC
 1Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio; 2Mount Sinai Hospital, Toronto; 3University Health Network -Toronto General Hospital; 4University of Toronto



Abstract:

Introduction: For patients with severe ARDS supported on ECMO, the optimal sedation and analgesia strategy is unknown.
Objective: To characterize pharmacological practice in a high-volume ECMO center and describe sedation depth, incidence of delirium, and mobilization in this population.
Methods: We conducted a retrospective study to describe medication (sedative, analgesic, paralytic, antipsychotic) administration in 45 patients treated with VV-ECMO for ARDS at Toronto General Hospital from July 2012-October 2015. Daily, from ECMO initiation to 72 hours after ECMO discontinuation, we recorded Sedation-Agitation Scale (SAS) scores, medications administered, routes and doses, delirium assessments, and mobilization.
Results: 45 adults (33 males, 45±12 years, APACHE II 30±6) with severe ARDS (P/F 74±23), primarily due to pulmonary sepsis (91%), were treated with VV-ECMO. Median duration of VV-ECMO was 11 days (IQR 7-17). 10 (22%) patients died on ECMO. At 48 hrs post ECMO initiation 96% of patients were deeply sedated (SAS<3) with continuous infusions of midazolam (53%), propofol (18%) or both (29%) and 98% of patients received opioid (fentanyl, 93%) infusions. 40% of patients were still deeply sedated 24 hrs prior to ECMO discontinuation (17%, survivors) or prior to withdrawal of care (23%, non-survivors). At this time, 75% were receiving sedatives (44% infusions, 31% intermittent) and 89% were receiving opioids (67% infusions, 22% intermittent). Following ECMO initiation patients spent a median of 6 days (IQR 3-10) deeply sedated before their first light or intermediate day. Patients who tolerated ≥1 day of intermediate or light levels of sedation during ECMO treatment (78%), still spent 64% (IQR 43-92%) of their ECMO days deeply sedated. 80% of patients were paralyzed with cisatracurim infusions (56%), rocuronium boluses (13%) or both (11%) while on ECMO. Median duration of cisatracurim infusion was 24 hrs (IQR 12-98). 71% of patients received physical therapy after a median of 7 days (IQR 4-12) on ECMO and the maximum mobility achieved by the majority (59%) was passive range of motion.The CAM-ICU or ICSDC score was positive for delirium in 79% of all patients and 24% of patients were very agitated (SAS>6) at least once. During ECMO, haloperidol and quetiapine were the primary antipsychotics used (49% and 76% of patients, respectively) and physical restraints were used in 40%. 
 Conclusons: Patients with severe ARDS were deeply sedated with midazolam and/or propofol and fentanyl infusions immediately after VV-ECMO initiation. The majority of surviving patients achieved light levels of sedation, few patients achieved active mobilization and almost all patients had a positive delirium screen while on ECMO


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