• James B Schneider, Todd Sweberg, Lisa A Asaro, Aileen Kirby, David Wypij, Ravi R Thiagarajan, Curley Martha A Q MAQ, and Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators.
• 1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cohen Children's Medical Center, Hofstra-Northwell School of Medicine, New York, NY. 2Department of Cardiology, Boston Children's Hospital, Boston, MA. 3Division of Pediatric Critical Care Medicine, Oregon Health & Science University School of Medicine, Portland, OR. 4Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA. 5Department of Pediatrics, Harvard Medical School, Boston, MA. 6Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA. 7Division of Anesthesia and Critical Care Medicine at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. 8Critical Care and Cardiovascular Program, Boston Children's Hospital, Boston, MA.
• Crit. Care Med. 2017 Oct 1; 45 (10): e1001-e1010.

ObjectivesTo describe sedation management in children supported on extracorporeal membrane oxygenation for acute respiratory failure.DesignSecondary analysis of prospectively collected data from a multicenter randomized trial of sedation (Randomized Evaluation of Sedation Titration for Respiratory Failure).SettingTwenty-one U.S. PICUs.PatientsOne thousand two hundred fifty-five children, 2 weeks to 17 years old, with moderate/severe pediatric acute respiratory distress syndrome.InterventionsSedation managed per usual care or Randomized Evaluation of Sedation Titration for Respiratory Failure protocol.Measurements And Main ResultsSixty-one Randomized Evaluation of Sedation Titration for Respiratory Failure patients (5%) with moderate/severe pediatric acute respiratory distress syndrome were supported on extracorporeal membrane oxygenation, including 29 managed per Randomized Evaluation of Sedation Titration for Respiratory Failure protocol. Most extracorporeal membrane oxygenation patients received neuromuscular blockade (46%) or were heavily sedated with State Behavioral Scale scores -3/-2 (34%) by extracorporeal membrane oxygenation day 3. Median opioid and benzodiazepine doses on the day of cannulation, 0.15 mg/kg/hr (3.7 mg/kg/d) and 0.11 mg/kg/hr (2.8 mg/kg/d), increased by 36% and 58%, respectively, by extracorporeal membrane oxygenation day 3. In the 41 patients successfully decannulated prior to study discharge, patients were receiving 0.40 mg/kg/hr opioids (9.7 mg/kg/d) and 0.39 mg/kg/hr benzodiazepines (9.4 mg/kg/d) at decannulation, an increase from cannulation of 108% and 192%, respectively (both p < 0.001). Extracorporeal membrane oxygenation patients experienced more clinically significant iatrogenic withdrawal than moderate/severe pediatric acute respiratory distress syndrome patients managed without extracorporeal membrane oxygenation support (p < 0.001). Compared to extracorporeal membrane oxygenation patients managed per Randomized Evaluation of Sedation Titration for Respiratory Failure protocol, usual care extracorporeal membrane oxygenation patients received more opioids during the study period (mean cumulative dose of 183.0 vs 89.8 mg/kg; p = 0.02), over 6.5 greater exposure days (p = 0.002) with no differences in wakefulness or agitation.ConclusionsIn children, the initiation of extracorporeal membrane oxygenation support is associated with deep sedation, substantial sedative exposure, and increased frequency of iatrogenic withdrawal syndrome. A standardized, goal-directed, nurse-driven sedation protocol may help mitigate these effects.

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