Table 3.
Sedation Profiles of ECMO Patients By Day around Decannulationa
| Variables | 3 days earlier (n = 39) | 2 days earlier (n = 41) | 1 day earlier (n = 41) | Day of decannulation (n = 41) | 1 day later (n = 41) | 2 days later (n = 41) | 3 days later (n = 40) |
|---|---|---|---|---|---|---|---|
| Sedatives administered | |||||||
| Opioid dose, median (IQR), mg/kgb | 7.3 (3.7–11.2) | 7.7 (4.3–11.5) | 7.8 (4.9–12.5) | 9.7 (5.2–14.5) | 8.1 (4.8–13.2) | 7.1 (4.4–11.3) | 5.1 (3.0–12.3) |
| Number of opioid bolus doses, median (IQR) | 5 (2–7) | 5 (2–8) | 5 (3–8) | 5 (3–8) | 3 (1–6) | 4 (1–7) | 1.5 (0–5) |
| Benzodiazepine dose, median (IQR), mg/kgc | 6.2 (3.6–12.6) | 7.3 (4.3–11.7) | 7.7 (5.1–12.6) | 9.4 (6.2–13.0) | 8.7 (4.8–12.6) | 7.5 (4.8–13.3) | 6.5 (3.6–12.5) |
| Number of benzodiazepine bolus doses, median (IQR) | 4 (2–7) | 4 (1–9) | 5 (2–7) | 5 (1–8) | 4 (1–6) | 3 (1–6) | 1.5 (0–5.5) |
| Secondary sedatives, n (%) | |||||||
| Dexmedetomidine | 10 (26) | 12 (29) | 11 (27) | 11 (27) | 14 (34) | 13 (32) | 14 (35) |
| Propofol | 0 | 1 (2) | 2 (5) | 2 (5) | 0 | 0 | 1 (3) |
| Barbiturates | 7 (18) | 10 (24) | 12 (29) | 13 (32) | 12 (29) | 9 (22) | 8 (20) |
| Ketamine | 5 (13) | 4 (10) | 5 (12) | 7 (17) | 5 (12) | 2 (5) | 3 (8) |
| Clonidine | 3 (8) | 4 (10) | 4 (10) | 4 (10) | 4 (10) | 5 (12) | 5 (13) |
| Methadone | 1 (3) | 1 (2) | 1 (2) | 1 (2) | 6 (15) | 10 (24) | 15 (38) |
| Chloral hydrate | 1 (3) | 1 (2) | 1 (2) | 1 (2) | 3 (7) | 3 (7) | 2 (5) |
| Number of different sedative classes received, median (IQR)d | 2 (2–3) | 2 (2–3) | 3 (2–3) | 3 (2–3) | 3 (2–3) | 3 (2–3) | 2.5 (2–3) |
| Sedation-related adverse eventse | |||||||
| Inadequate pain management, n (%) | 3 (8) | 1 (2) | 2 (5) | 0 | 2 (5) | 3 (7) | 2 (5) |
| Inadequate sedation management, n (%) | 2 (5) | 2 (5) | 2 (5) | 2 (5) | 4 (10) | 6 (15) | 3 (8) |
| Clinically significant iatrogenic withdrawal, n (%) | 0 | 0 | 0 | 0 | 0 | 1 (2) | 2 (5) |
| Sedation scoresf | (n = 38) | (n = 39) | (n = 38) | (n = 40) | (n = 40) | (n = 37) | (n = 39) |
| Modal SBS score, n (%) | |||||||
| +1/+2 | 0 | 0 | 0 | 0 | 3 (8) | 1 (3) | 3 (8) |
| −1/0 | 8 (21) | 13 (33) | 10 (26) | 12 (30) | 22 (55) | 27 (73) | 24 (62) |
| −3/−2 | 11 (29) | 6 (15) | 8 (21) | 9 (23) | 6 (15) | 3 (8) | 3 (8) |
| Neuromuscular blockade entire day | 19 (50) | 20 (51) | 20 (53) | 19 (48) | 9 (23) | 6 (16) | 3 (8) |
| No longer intubated | 0 | 0 | 0 | 0 | 0 | 0 | 6 (15) |
| Lowest SBS score, n (%) | |||||||
| +1/+2 | 0 | 0 | 0 | 0 | 1 (3) | 0 | 0 |
| −1/0 | 3 (8) | 6 (15) | 5 (13) | 8 (20) | 14 (35) | 22 (59) | 23 (59) |
| −3/−2 | 16 (42) | 13 (33) | 13 (34) | 13 (33) | 16 (40) | 9 (24) | 7 (18) |
| Neuromuscular blockade entire day | 19 (50) | 20 (51) | 20 (53) | 19 (48) | 9 (23) | 6 (16) | 3 (8) |
| No longer intubated | 0 | 0 | 0 | 0 | 0 | 0 | 6 (15) |
| Highest SBS score, n (%) | |||||||
| +1/+2 | 6 (16) | 9 (23) | 7 (18) | 10 (25) | 14 (35) | 20 (54) | 22 (56) |
| −1/0 | 9 (24) | 9 (23) | 10 (26) | 8 (20) | 15 (38) | 11 (30) | 7 (18) |
| −3/−2 | 4 (11) | 1 (3) | 1 (3) | 3 (8) | 2 (5) | 0 | 1 (3) |
| Neuromuscular blockade entire day | 19 (50) | 20 (51) | 20 (53) | 19 (48) | 9 (23) | 6 (16) | 3 (8) |
| No longer intubated | 0 | 0 | 0 | 0 | 0 | 0 | 6 (15) |
ECMO = extracorporeal membrane oxygenation, IQR = interquartile range, SBS = State Behavioral Scale.
Excluded 20 patients who were not decannulated prior to study discharge (10 patients died on ECMO support, 8 patients still on ECMO on Day 28, and 2 patients still on ECMO on day of transfer to non-participating pediatric intensive care unit).
Opioid doses were calculated as morphine equivalents in mg/kg, including morphine (1), fentanyl (0.015), methadone (0.3), enteral codeine (20), hydromorphone (0.15), enteral oxycodone (3), and remifentanil (0.015).
Benzodiazepine doses were calculated as midazolam equivalents in mg/kg, including midazolam (1), clonazepam (0.2), lorazepam (0.3), and diazepam (2).
Different sedatives classes include opioids, benzodiazepines, α2-adrenergic agonists, propofol, barbiturates, ketamine, and chloral hydrate.
Inadequate pain management: pain score >4 [or pain assumed present if receiving neuromuscular blockade] for 2 consecutive hours; inadequate sedation management: SBS score >0 [or agitation assumed present if receiving neuromuscular blockade] for 2 consecutive hours; clinically significant iatrogenic withdrawal in patients weaning from 5 or more days of opioids: rescue therapy to manage an increase in WAT-1 symptoms.
The SBS scores range from −3 (unresponsive) to +2 (agitated).