Analgesia, sedation, and mobilization practices in pediatric patients supported with extracorporeal membrane oxygenation across Europe: an ESPNIC survey.

Appropriate analgosedation and mobilization are essential elements of care in critically ill children. On extracorporeal membrane oxygenation (ECMO), analgosedation and mobilization are tailored to individual pharmacokinetics and mobilization risks. We aimed to investigate analgosedation and mobilization practices in pediatric ECMO across Europe. We performed a multicenter cross-sectional survey-based study. We surveyed one experienced physician per pediatric ECMO center in Europe (March-July 2025). Additionally, we investigated differences in practices based on ECMO volume (≤ 10 vs > 10 cases/year) and ICU type (exclusively pediatric ICU vs other ICUs). Among 123 ECMO centers, 96 (77%) responded, across 19 countries. Fifty-two percent of centers managed > 10 ECMO/year; 68% had exclusively pediatric ICUs. Nineteen percent of centers had a dedicated ECMO-analgosedation protocol. Most centers applied the same analgesic (81%) and sedative (80%) strategies used for non-ECMO patients, though higher doses were often reached on ECMO (62%). Morphine and fentanyl were the preferred first-line analgesics, with fentanyl more used in exclusively pediatric ICUs (p = 0.013); midazolam was the preferred first-line sedative (61%) followed by dexmedetomidine (24%); dexmedetomidine, propofol, and ketamine were the most used second- and third-line agents. Analgosedation, iatrogenic withdrawal, and delirium monitoring tools were widely used, yet 16% and 26% of centers did not use any iatrogenic withdrawal syndrome or delirium tools, respectively. Eighty-one percent of centers implemented mobilization; higher ECMO-volume centers implemented mobilization (p = 0.022), awake-ECMO strategies (p = 0.041), and proning (p = 0.009) more frequently compared to lower ECMO-volume centers.

conclusionsManagement of analgosedation in pediatric ECMO patients mirrors that used for non-ECMO patients, though higher doses are reached on ECMO. Only 19% of the centers have a dedicated ECMO-analgosedation protocol. Midazolam is still widely used over alpha-agonists. Mobilization practices are particularly implemented in higher ECMO-volume centers. Further research and education are needed to define best practices and improve outcomes for this population. WHAT IS KNOWN: • Appropriate analgosedation and mobilization are essential elements of care in critically ill children. On ECMO, analgosedation and mobilization are challenging and should be tailored to individual pharmacokinetics and mobilization risks. • Limited data, evidence, and dedicated guidelines exist on this topic. WHAT IS NEW: • Management of analgosedation in pediatric ECMO patients in Europe largely mirrors that used for non-ECMO patients, though higher maximum doses were reached on ECMO. Only 19% of centers have a dedicated analgosedation protocol for ECMO-patients. Morphine and fentanyl are the most used analgesics. Midazolam is still widely used as first-line sedative, despite recent pediatric guidelines advocating for alpha-agonists. Mobilization practices are particularly implemented in centers with higher ECMO-volume, reflecting a broader cultural shift toward minimizing sedation and promoting rehabilitation. • Further research and standardized education are needed to define best practices and ultimately improve outcomes for this high-risk patient population.