Sedation Practices in Pediatric Extracorporeal Membrane Oxygenation

Introduction:Children on extracorporeal membrane oxygenation (ECMO) support need adequate sedation and analgesia for optimal care.Often, they need neuromuscular blocking agents (NMBAs).These drugs are associated with adverse consequences.The current survey was done to identify the sedation practices in children on ECMO support.Materials and methods: An online survey was conducted via Google form in December 2023.The Google form was circulated among the members of the ECMO Society of India and personal contacts.ECMO specialists and pediatric intensivists performing pediatric ECMO were requested to respond.The survey had 29 questions in five domains: demographics, drug details, protocols, sedation withdrawal, and outcomes.Results: There were 19 responses in the survey from across eight states, and were predominantly from non-government organizations.All except one used a combination of sedatives and analgesics for optimal sedation; midazolam and fentanyl were the most common combination (44%).About 37% of the respondents used dexmedetomidine as the first-line sedative agent.Two thirds of the respondents reported that children on ECMO have greater difficulty in achieving adequate sedation and 42% used sedative and analgesic doses higher than the usual doses.About 37% of all children received NMBAs.Two-thirds of the respondents never practice awake ECMO.Ramsay sedation scale (RSS) (36.8%) and richmond agitation sedation scale (RASS) (31.6%) were commonly used for sedation assessment and withdrawal assessment tool (WAT-1) (63.2%) was the most commonly used withdrawal scale.Nearly 80% of the respondents reported that sedation-related adverse events (SRAEs) affect the overall outcomes including the duration of ventilation or duration of pediatric intensive care unit (PICU) stay or duration of hospital stay in children on ECMO. Conclusion:In this survey, we observed that a combination of benzodiazepines and opioids was the preferred agent with increasing use of dexmedetomidine as a first-line agent in children on ECMO.A greater proportion of children on ECMO have difficulty in achieving optimal sedation and need for higher doses or NMBAs.Future studies should focus on reporting sedation practices, effects on outcomes, and methods to improve outcomes related to sedation in children on ECMO.Clinical significance: Sedation in children on ECMO poses a challenge and optimal sedation strategies to be employed for best results minimizing adverse consequences.