Optimizing Drug Therapy in ECMO-Supported Critically Ill Adults: A Narrative Review and Clinical Guide

Area of Science:

• Critical Care Medicine
• Clinical Pharmacology
• Pharmacokinetics and Pharmacodynamics

Background:

• Extracorporeal membrane oxygenation (ECMO) is vital for severe cardiac/respiratory failure.
• ECMO circuits and critical illness alter drug pharmacokinetics (PK) and pharmacodynamics (PD).
• Optimizing pharmacotherapy in ECMO patients presents significant challenges.

Purpose of the Study:

• To review current clinical evidence on ECMO-related PK/PD alterations.
• To provide practical guidance for drug dosing and monitoring in adult ECMO patients.
• To synthesize data on commonly used therapeutic classes in ECMO.

Main Methods:

• A structured literature search was performed from January to May 2025.
• Databases searched included PubMed/MEDLINE, EMBASE, Scopus, and others.
• Included studies were clinical trials, observational studies, reviews, and guidelines in adults.

Main Results:

• Hydrophilic drugs (e.g., beta-lactams, aminoglycosides) showed minimal ECMO-specific PK changes.
• Lipophilic drugs (e.g., fentanyl, propofol) exhibited significant circuit adsorption and variability.
• Data for some drug classes like neuromuscular blockers and antivirals were limited.

Conclusions:

• Individualized dosing is essential for optimizing pharmacotherapy in ECMO patients.
• Therapeutic drug monitoring (TDM) and PK principles are critical for guiding treatment.
• Further research is needed for specific drug classes lacking ECMO-specific data.