Optimize Medications for Patients Receiving ECMO
Overview
As a critical care pharmacist, you will get questions about optimal medication management for patients receiving extracorporeal membrane oxygenation (ECMO). ECMO serves as a bridge for critically ill patients with cardiac or respiratory failure not responding to standard treatment.
It takes venous blood, oxygenates it, removes carbon dioxide and returns it to the patient. But data are limited on how ECMO impacts med requirements. Offer practical considerations for commonly used meds.
Clinical practice
Analgesics and sedatives
Most first-line options (fentanyl, midazolam, propofol, etc) can be sequestered by the ECMO machine, since these meds are lipophilic and highly protein-bound. But clinical data don’t always match kinetic predictions.
- Generally start with routine drugs and standard doses. Then consider higher dosing limits if needed such as for titratable sedatives in ECMO patients requiring deep sedation.
- Or shift to an alternative agent. For example, some hospitals use hydromorphone as the preferred analgesic with ECMO since it’s more hydrophilic than fentanyl.
Anticoagulants
Most ECMO patients receive full systemic anticoagulation, often with heparin, due to risk of the machine clotting off, which may cause mechanical failure or thromboembolism. Monitor multiple parameters if possible, such as aPTT plus anti-Xa levels due to higher bleeding and clotting risk. And expect debate over anticoagulant intensity and which agent to choose as data evolve. For example, limited evidence suggests that bivalirudin may result in fewer thromboses than heparin. Work with your colleagues to standardize options.
Antimicrobials
Dose adjustments may be needed with certain beta-lactams and antifungals due to sequestration by the ECMO machine or kinetic changes, such as larger volume of distribution.
- For example, consider increasing meropenem doses to 2 g AND giving as extended infusions to help achieve pharmacodynamic targets when using it for harder-to-treat pathogens (ESBL, etc).
- Or work with ID to fine-tune caspofungin or micafungin dosing. For instance, some experts bump micafungin doses up to 150 mg daily, based on kinetic studies.
References
- Patel JS, Kooda K, Igneri LA. A Narrative Review of the Impact of Extracorporeal Membrane Oxygenation on the Pharmacokinetics and Pharmacodynamics of Critical Care Therapies. Ann Pharmacother. 2023;57(6):706-726.
- Kido K, Kabulski GM, Szymanski TW, Shiga T, Shimizu M, Hashiguchi M. Meta-Analysis Comparing Bivalirudin Versus. Unfractionated Heparin in Adult Patients With Extracorporeal Membrane Oxygenation. J Pharm Pract. 2024;37(2):429-434.
- McMichael ABV, Ryerson LM, Ratano D, Fan E, Faraoni D, Annich GM. 2021 ELSO Adult and Pediatric Anticoagulation Guidelines. ASAIO J. 2022;68(3):303-310.
This note has been edited and reviewed by the pharmacy doctors on NPS team.
- Published on March 12, 2025
- This note last updated in N/A
