DRUG DOSING AND PHARMACOLOGICAL EFFECTS IN ECMO: A COMPREHENSIVE REVIEW
DOI:
https://doi.org/10.22159/ijpps.2026v18i5.58333Keywords:
Extracorporeal membrane oxygenation (ECMO), Pharmacokinetics, Therapeutic drug monitoring (TDM), Drug sequestration, AntimicrobialsAbstract
Extracorporeal membrane oxygenation (ECMO) serves as a critical life-support modality for patients with severe cardiac or respiratory failure, yet the large surface area of the circuit introduces significant variability in the pharmacokinetics (PK) and pharmacodynamics (PD) of essential medications. This systematic review evaluates clinical evidence from 2015 to 2025 regarding drug dosing alterations in adult ECMO patients, focusing on anticoagulants, antibacterials, antifungals, and antivirals. Our analysis identifies drug sequestration as a primary determinant of therapeutic failure, particularly for highly lipophilic agents like voriconazole and fentanyl, which exhibit circuit losses exceeding 70% within hours of administration. Conversely, hydrophilic antibiotics such as beta-lactams and glycopeptides are primarily impacted by an increased volume of distribution (Vd) and augmented renal clearance, often necessitating loading dose increases of 20–50% or the use of extended infusions to maintain therapeutic levels. Regarding anticoagulation, evidence supports the superiority of anti-Xa (target 0.3–0.7 IU/mL) and viscoelastic assays over activated clotting time (ACT) for minimizing hemorrhagic risks. Current dosing guidelines remain fragmented; thus, clinicians must adopt individualized strategies involving aggressive therapeutic drug monitoring (TDM) and multimodal anticoagulation assessment to ensure efficacy and safety in this high-risk population.
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