Adaptive periodic paralysis allows weaning deep sedation overcoming the drowning syndrome in ECMO patients bridged for lung transplantation: A case series ☆ Irina Timofte a, ⁎ ,1 , Michael Terrin b,2 , Erik Barr b,2 , June Kim a,1 , Joseph Rinaldi f , Nicholas Ladikos e,3 , Jay Menaker d,4 , Ali Tabatabai a,d,5 , Zachary Kon c,6 , Bartley Griffith c,7 , Richard Pierson c,8 , Si Pham c,6 , Aldo Iacono d,9 , Daniel Herr a,10 a Department of Medicine, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, United States b Department of Epidemiology, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, United States c Department of Cardio Thoracic Surgery, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, United States d Department of R Adams Cowley Shock Trauma, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, United States e Suburban Hospital/Johns Hopkins Medicine, 8600 Old Georgetown Road, Bethesda, MD, United States f Johns Hopkins University, 1800 Orleans Street, Baltimore, MD, United States abstract article info Available online xxxx Purpose: Sedation in extracorporeal membrane oxygenation (ECMO) is challenging. Patients require deep seda- tion because of extremely high respiratory rates and increased work of breathing (“Drowning Syndrome”) resulting in altered intra-thoracic pressure and reduced pump flow associated with hemodynamic compromise and decreased oxygenation. However, deep sedation impedes essential active rehabilitation with physical ther- apy. Methods: We reviewed data on 3 ECMO patients for whom we used a novel approach to replace continuous drips with periodic sedation/paralysis. Initially our patients were on high dose narcotics, propofol, and dexmedetomidine and unable to interact and breathe comfortably. IV narcotics were weaned over 24 h and were replaced by methadone. Dexmedetomidine was continued in order to block hyperadrenergic events. Propofol was weaned at a prescribed rate. When patients demonstrated agitation, decreased pump flow and he- modynamic compromise, diazepam was given in combination with a paralytic. Results: By replacing IV narcotic and propofol, with PRN diazepam and vecuronium, patients were off continuous drips in 1 week and were able to actively participate in physical therapy. Conclusion: Allowing patients to wake up by rapid weaning of continuous narcotics and anesthetic agents using Dexmedetomidine and periodic paralysis to favorably alter hemodynamics is a successful method to wean deep sedation in ECMO. © 2017 Published by Elsevier Inc. Keywords: ECMO Lung transplant Sedation Journal of Critical Care 42 (2017) 157–161 ☆ The authors have no significant conflicts of interest with any companies or organization whose products or services may be discussed in this article. ⁎ Corresponding author at: 110 S Paca Street, 2nd Floor, Baltimore, MD 21201, United States. E-mail address: IrTimofte@SOM.umaryland.edu (I. Timofte). 1 University of Maryland School of Medicine,110 S Paca Street, Baltimore, Maryland, United States, Department of Medicine, Division of Pulmonary and Critical Care. 2 University of Maryland School of Medicine, 660 W Redwood, Baltimore, Maryland, United States, Department of Epidemiology and Public Health. 3 Suburban Hospital/Johns Hopkins Medicine, 8600 Old Georgetown Road, Bethesda, Maryland, United States, Department of Pharmacy. 4 University of Maryland, 22 S Greene St, Baltimore, Maryland, United States, Department of Surgery, R Adams Cowley Shock Trauma Center. 5 University of Maryland, 22 S Greene St Baltimore, Maryland, United States, Department of Medicine, R Adams Cowley Shock Trauma Center. 6 University of Maryland School of Medicine, 110 S Paca Street, Baltimore, Maryland, United States, Department of Surgery, Division of Cardiac Surgery. 7 University of Maryland Medical Center, 110 S Paca Street, Baltimore, Maryland, United States, Department of Surgery, Division of Cardiac Surgery. 8 University of Maryland School of Medicine and VA Maryland Health Care System, 110 S Paca Street, Baltimore, Maryland, United States, Department of Surgery, Division of Cardiac Surgery. 9 University of Maryland School of Medicine, Baltimore, Maryland, United States, Departments of Medicine and Surgery, R Adams Cowley Shock Trauma Center. 10 University of Maryland School of Medicine, 22 S Greene St, Baltimore, Maryland, United States, Department of Medicine and Surgery, Chief Of Surgical Critical Care. http://dx.doi.org/10.1016/j.jcrc.2017.07.033 0883-9441/© 2017 Published by Elsevier Inc. Contents lists available at ScienceDirect Journal of Critical Care journal homepage: www.jccjournal.org