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VOLUME 2 , ISSUE 1 ( January-March, 2024 ) > List of Articles


Sedation Practices in Pediatric Extracorporeal Membrane Oxygenation

Kiran K Banothu, Priyanka Gupta, Pranay Labhashankar Oza, Anil Sachdev

Keywords : Awake ECMO, Pediatric ECMO, Pediatric intensive care unit, Sedation, Sedation withdrawal

Citation Information : Banothu KK, Gupta P, Oza PL, Sachdev A. Sedation Practices in Pediatric Extracorporeal Membrane Oxygenation. Indian J ECMO 2024; 2 (1):18-23.

DOI: 10.5005/jaypee-journals-11011-0023

License: CC BY-NC 4.0

Published Online: 19-06-2024

Copyright Statement:  Copyright © 2024; The Author(s).


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.

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  1. Hill JD, O'Brien TG, Murray JJ, et al. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med 1972;286(12):629–634. DOI: 10.1056/NEJM197203232861204.
  2. Bartlett RH. Esperanza: The first neonatal ECMO patient. ASAIO J 2017;63(6):832–843. DOI: 10.1097/MAT.0000000000000697.
  3. Zapol WM, Snider MT, Hill JD, et al. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA 1979;242(20):2193–2196. DOI: 10.1001/jama.242.20.2193.
  4. Barbaro RP, Paden ML, Guner YS, et al. Pediatric extracorporeal life support organization registry international report 2016. ASAIO J 2017;63(4):456–463. DOI: 10.1097/MAT.0000000000000603.
  5. ELSO. ECLS International Summary of Statistics: ECMO - Extracorporeal Membrane Oxygenation. 2023. Available from:
  6. Zimmerman KO, Dallefeld SH, Hornik CP, et al. Sedative and analgesic pharmacokinetics during pediatric ECMO. J Pediatr Pharmacol Ther 2020;25(8):675–688. DOI: 10.5863/1551-6776-25.8.675.
  7. DeBerry BB, Lynch JE, Chernin JM, et al. A survey for pain and sedation medications in pediatric patients during extracorporeal membrane oxygenation. Perfusion 2005;20(3):139–143. DOI: 10.1191/0267659105pf801oa.
  8. Garcia Guerra G, Joffe AR, Cave D, et al. Survey of sedation and analgesia practice among canadian pediatric critical care physicians. Pediatr Crit Care Med 2016;17(9):823–830. DOI: 10.1097/PCC.0000000000000864.
  9. Egbuta C, Mason KP. Current state of analgesia and sedation in the pediatric intensive care unit. J Clin Med 2021;10(9):1847. DOI: 10.3390/jcm10091847.
  10. Vet NJ, Ista E, de Wildt SN, et al. Optimal sedation in pediatric intensive care patients: A systematic review. Intensive Care Med 2013;39(9):1524–1534. DOI: 10.1007/s00134-013-2971-3.
  11. Schneider JB, Sweberg T, Asaro LA, et al. Sedation management in children supported on extracorporeal membrane oxygenation for acute respiratory failure. Crit Care Med 2017;45(10):e1001–e1010. DOI: 10.1097/CCM.0000000000002540.
  12. Buscher H, Vaidiyanathan S, Al-Soufi S, et al. Sedation practice in veno-venous extracorporeal membrane oxygenation: An international survey. ASAIO J 2013;59(6):636–641. DOI: 10.1097/MAT.0b013e3182a84558.
  13. Dzierba AL, Abrams D, Madahar P, et al. Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation. J Crit Care 2019;53:98–106. DOI: 10.1016/j.jcrc.2019.05.014.
  14. Oza PL, Shukla PJ, Goyal VS. Sedation management on ECMO. Indian J ECMO 2023;1(1):15–22. DOI: 10.5005/jaypee-journals-11011-0002.
  15. Anton-Martin P, Modem V, Taylor D, et al. A retrospective study of sedation and analgesic requirements of pediatric patients on extracorporeal membrane oxygenation (ECMO) from a single-center experience. Perfusion 2017;32(3):183–191. DOI: 10.1177/0267659116670483.
  16. Bakhsh MA, Humoodi MOM, Alzahrani AM, et al. Sedation and analgesia practices of pediatric intensivists in Saudi Arabia. Saudi Critical Care Journal 2023;7(1):1–7. DOI: 10.4103/sccj.sccj_25_22.
  17. Jiang L, Ding S, Yan H, et al. A Retrospective comparison of dexmedetomidine versus midazolam for pediatric patients with congenital heart disease requiring postoperative sedation. Pediatr Cardiol 2015;36(5):993–999. DOI: 10.1007/s00246-015-1110-z.
  18. Sperotto F, Mondardini MC, Dell'Oste C, et al. Pediatric Neurological Protection and Drugs (PeNPAD) Study Group of the Italian Society of Neonatal and Pediatric Anesthesia and Intensive Care (SARNePI). Efficacy and safety of dexmedetomidine for prolonged sedation in the PICU: A prospective multicenter study (PROSDEX). Pediatr Crit Care Med 2020;21(7):625–636. DOI: 10.1097/PCC.0000000000002350.
  19. Daverio M, Sperotto F, Stefani C, et al. Neuromuscular blocker use in critically Ill children: Assessing mortality risk by propensity score–weighted analysis. Crit Care Med 2022;50(3):e294–e303. DOI: 10.1097/CCM.0000000000005334.
  20. Curley MAQ, Wypij D, Watson RS, et al. Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: A randomized clinical trial. JAMA 2015;313(4): 379–389. DOI: 10.1001/jama.2014.18399.
  21. Schmidt F, Jack T, Sasse M, et al. “Awake veno-arterial extracorporeal membrane oxygenation” in pediatric cardiogenic shock: A single-center experience. Pediatr Cardiol 2015;36(8):1647–1656. DOI: 10.1007/s00246-015-1211-8.
  22. Schmidt F, Sasse M, Boehne M, et al. Concept of “awake venovenous extracorporeal membrane oxygenation” in pediatric patients awaiting lung transplantation. Pediatr Transplant 2013;17(3):224–230. DOI: 10.1111/petr.12001.
  23. Duceppe MA, Perreault MM, Frenette AJ, et al. Frequency, risk factors and symptomatology of iatrogenic withdrawal from opioids and benzodiazepines in critically Ill neonates, children and adults: A systematic review of clinical studies. J Clin Pharm Ther 2019; 44(2):148–156. DOI: 10.1111/jcpt.12787.
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