Extracorporeal membrane oxygenation (ECMO), which can support gas exchange or hemodynamics in patients with severe respiratory or cardiac failure, has demonstrated considerable evolution over the last decade [1], with a steady rise since 2009 in the number of ECMO‐treated patients and number of centers providing ECMO support [2, 3]. With more adult patients being placed on ECMO support, there is an increased need to understand the complex changes in drug pharmacokinetics and pharmacodynamics that occur with the addition of an ECMO circuit to the management of a critically ill patient.

The relationship between the dose of a drug and the elicited response may be altered in critically ill patients as a result of pharmacokinetic and pharmacodynamic changes [4]. The use of extracorporeal mechanical support, such as ECMO, can further increase the variability of pharmacokinetic alterations [5]. Therefore, the combination of critical illness and ECMO presents considerable challenges to providing optimal pharmacotherapy. The ability to anticipate alterations in pharmacokinetics and pharmacodynamics in this patient population is essential for providing an individualized therapeutic plan that maximizes therapeutic benefit while minimizing potential toxicity.

Despite improvements in extracorporeal technology and resurgence in its use in respiratory and cardiac failure, there remains a paucity of data on pharmacotherapy in patients receiving ECMO. This chapter summarizes our current understanding of the effects of ECMO on the pharmacokinetics and pharmacodynamics of several drug classes commonly used to manage these critically ill patients.