Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.
Ann Pharmacother. 2023 Jun;57(6):706-726. doi: 10.1177/10600280221126438. Epub 2022 Oct 15.
Extracorporeal membrane oxygenation (ECMO) utilization is increasing on a global scale, and despite technological advances, minimal standardized approaches to pharmacotherapeutic management exist. This objective was to create a comprehensive review for medication dosing in ECMO based on the most current evidence.
A literature search of PubMed was performed for all pertinent articles prior to 2022. The following search terms were utilized: ECMO, pharmacokinetics, pharmacodynamics, sedation, analgesia, antiepileptic, anticoagulation, antimicrobial, antifungal, nutrition. Retrospective cohort studies, case-control studies, case series, case reports, and ex vivo investigations were reviewed.
PubMed (1975 through July 2022) was the database used in the literature search. Non-English studies were excluded. Search terms included both drug class categories, specific drug names, ECMO, and pharmacokinetics.
Medications with high protein binding (>70%) and high lipophilicity (logP > 2) are associated with circuit sequestration and the potential need for dose adjustment. Volume of distribution changes with ECMO may also impact dosing requirements of common critical care medications. Lighter sedation targets and analgosedation may help reduce sedative and analgesia requirements, whereas higher antiepileptic dosing is recommended. Vancomycin is minimally affected by the ECMO circuit and recommendations for dosing in critically ill adults are reasonable. Anticoagulation remains challenging as optimal aPTT goals have not been established.
This review describes the anticipated impacts of ECMO circuitry on sedatives, analgesics, anticoagulation, antiepileptics, antimicrobials, antifungals, and nutrition support and provides recommendations for drug therapy management.
Medication pharmacokinetic/pharmacodynamic parameters should be considered when determining the potential impact of the ECMO circuit on attainment of therapeutic effect and target serum drug concentrations, and should guide therapy choices and/or dose adjustments when data are not available.
体外膜肺氧合（ECMO）在全球范围内的应用正在增加，尽管技术在不断进步，但对于治疗管理的标准化方法几乎没有。本目标旨在根据最新证据，为 ECMO 中的药物剂量制定全面的综述。
在 2022 年之前，对 PubMed 进行了文献检索，以查找所有相关文章。使用了以下搜索词：ECMO、药代动力学、药效动力学、镇静、镇痛、抗癫痫、抗凝、抗菌、抗真菌、营养。回顾了回顾性队列研究、病例对照研究、病例系列、病例报告和离体研究。
使用 PubMed（1975 年至 2022 年 7 月）进行文献检索。排除非英语研究。搜索词包括药物类别、特定药物名称、ECMO 和药代动力学。
蛋白结合率（>70%）和脂溶性（logP>2）高的药物与回路隔离有关，需要调整剂量。ECMO 可能会改变分布容积，这也会影响常见重症监护药物的剂量需求。较轻的镇静目标和镇痛镇静可能有助于减少镇静和镇痛需求，而较高的抗癫痫剂量则推荐。万古霉素受 ECMO 回路的影响较小，因此对重症患者的推荐剂量是合理的。抗凝仍然具有挑战性，因为尚未确定最佳 aPTT 目标。
本综述描述了 ECMO 电路对镇静剂、镇痛药、抗凝剂、抗癫痫药、抗菌药、抗真菌药和营养支持的预期影响，并为药物治疗管理提供了建议。
在确定 ECMO 电路对达到治疗效果和目标血清药物浓度的潜在影响时，应考虑药物药代动力学/药效学参数，并在没有数据时指导治疗选择和/或剂量调整。
