Appropriate sedation should be provided to patients requiring ECMO support as clinically indicated. Sedation may be required for a number of reasons, including but not limited to preventing ETT intolerance, ECMO circuit flow issues due to coughing, inadvertent vagal manoeuvres, and decreasing metabolic demands and oxygen consumption.

Choice of agents

On commencement of ECMO support, for sedation, we recommend the use of midazolam (5-10mg/ hr IV) if propofol is used larger doses may be required as sequestration of propofol occurring in the ECMO circuit.

For analgesia, we recommend the use of IV morphine over IV fentanyl as there is evidence of significant sequestration of fentanyl in the ECMO circuit and a reduced clinical effect for the patient.

Once a patient is safely established on ECMO support and/or the disease process is beginning to resolve we recommend the use of daily sedation holds to minimise sedation as per local guidelines. In patients requiring VV ECMO support, caution should be exercised when weaning sedation to prevent excessive respiratory effort causing further lung injury. Consideration of increasing the fresh gas flow, to reduce PaCO2 (e.g. ~30 mmHg) and therefore decreasing respiratory drive may facilitate this process.

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