Level of sedation in patients with COVID-19 supported with ECMO: A comparative analysis of the critical care consortium international database.

Summary

In a multicenter retrospective cohort of 328 COVID-19 patients on VV-ECMO, lighter sedation (without continuous NMBA) was associated with substantially lower 90-day in-hospital mortality (HR 3.23 for high vs low sedation) and fewer infectious/hemorrhagic complications, despite longer ECMO runs and more circuit changes. Baseline severity was similar except for lower PaO2/FiO2 in the high-sedation group.

Key Findings

• High sedation (continuous NMBA) was associated with a 3.23-fold higher hazard of death vs low sedation.
• Low-sedation patients had fewer infectious and hemorrhagic complications but longer ECMO runs and more circuit changes.
• Baseline disease severity was similar; PaO2/FiO2 was lower in the high-sedation group.

Clinical Implications

Consider targeting lighter sedation and avoiding continuous neuromuscular blockade during VV-ECMO for ARDS, with vigilance for longer ECMO duration and circuit management.

Limitations

• Retrospective observational design with potential confounding by indication
• Sedation exposure categorization may be imperfect; COVID-specific context may limit generalizability

Future Directions

Prospective trials comparing light vs deep sedation strategies during VV-ECMO, including patient-centered outcomes and neurocognitive sequelae.