The Challenges with Brain Death Determination in Adult Patients on Extracorporeal Membrane Oxygenation

Muralidharan, Rajanandini; Mateen, Farrah J.; Shinohara, Russell T.; Schears, Gregory J.; Wijdicks, Eelco F. M.

doi:10.1007/s12028-011-9516-9

Cited by 55 publications

(35 citation statements)

References 9 publications

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“…Three patients underwent brain death; one case was due to a trauma-related carotid dissection, one was due to meningitis and one was due to severe and prolonged hypoxemia (∼12 h) prior to ECMO administration. The former patientalso developed severe hypoxia-related rhabdomyolysis and hypoxic hepatitis, and he was the only patient who was determined to be brain dead while receiving ECMO support, which is a challenging diagnosis (26). …”

Section: Discussionmentioning

confidence: 99%

First-year experience of a Brazilian tertiary medical center in supporting severely ill patients using extracorporeal membrane oxygenation

Park

Azevedo

Mendes

et al. 2012

Clinics

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OBJECTIVES:The aim of this manuscript is to describe the first year of our experience using extracorporeal membrane oxygenation support.METHODS:Ten patients with severe refractory hypoxemia, two with associated severe cardiovascular failure, were supported using venous-venous extracorporeal membrane oxygenation (eight patients) or veno-arterial extracorporeal membrane oxygenation (two patients).RESULTS:The median age of the patients was 31 yr (range 14–71 yr). Their median simplified acute physiological score three (SAPS3) was 94 (range 84–118), and they had a median expected mortality of 95% (range 87–99%). Community-acquired pneumonia was the most common diagnosis (50%), followed by P. jiroveci pneumonia in two patients with AIDS (20%). Six patients were transferred from other ICUs during extracorporeal membrane oxygenation support, three of whom were transferred between ICUs within the hospital (30%), two by ambulance (20%) and one by helicopter (10%). Only one patient (10%) was anticoagulated with heparin throughout extracorporeal membrane oxygenation support. Eighty percent of patients required continuous venous-venous hemofiltration. Three patients (30%) developed persistent hypoxemia, which was corrected using higher positive end-expiratory pressure, higher inspired oxygen fractions, recruitment maneuvers, and nitric oxide. The median time on extracorporeal membrane oxygenation support was five (range 3–32) days. The median length of the hospital stay was 31 (range 3-97) days. Four patients (40%) survived to 60 days, and they were free from renal replacement therapy and oxygen support.CONCLUSIONS:The use of extracorporeal membrane oxygenation support in severely ill patients is possible in the presence of a structured team. Efforts must be made to recognize the necessity of extracorporeal respiratory support at an early stage and to prompt activation of the extracorporeal membrane oxygenation team.

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Section: Discussionmentioning

confidence: 99%

First-year experience of a Brazilian tertiary medical center in supporting severely ill patients using extracorporeal membrane oxygenation

Park

Azevedo

Mendes

et al. 2012

Clinics

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“…In one review of children who died on ECMO, brain death was determined in 29% of them but the protocol that was used was not described [18]. In another review of 87 patients on ECMO over an 8-year period, three met criteria for brain death but in two of them, apnea testing was deemed "too difficult to perform" and in the third, support was withdrawn before apnea testing could be done [19]. Hsieh and colleagues reported three patients supported by ECMO who underwent brain death testing.…”

Section: The Apnea Test With Ecmomentioning

confidence: 99%

“…Yang and colleagues [26] proposed decreasing the sweep gas flow rate to zero during apnea testing but that might make it hard to maintain adequate oxygenation at that level [19]. Thus most people have chosen 0.5 -1.0 L/min of sweep gas flow during apnea testing as an estimation of the optimal level balance between providing oxygenation and CO 2 clearance.…”

Section: The Apnea Test With Ecmomentioning

confidence: 99%

Apnea Testing for the Determination of Brain Death in Patients Supported by Extracorporeal Membrane Oxygenation

Talahma

DeGeorgia

2016

J Neurol Res

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The neurological criteria for brain death include coma, absent brain stem reflexes, and apnea. For patients on extracorporeal membrane oxygenation (ECMO), routine apnea testing is not possible because gas exchange occurs entirely through the membrane oxygenator. We describe the protocol we used to perform the apnea test and declare brain death in a patient on ECMO and review the literature of brain death testing in patients on ECMO. A 39-year-old female presented with cardiogenic shock followed by pulseless electrical activity (PEA) and eventually started on veno-arterial (VA) ECMO. Neurology was consulted for prognostication. Initial exam 48 hours after arrest showed absent brain stem reflexes. Another neurological exam 72 hours after arrest was compatible with brain death, so apnea test was performed. The apnea test involved preoxygenation, then she was disconnected from ventilator and the gas sweep rate decreased to 1 L/ minute while maintaining the same blood flow rate. At 10 minutes, the PCO 2 level needed to declare brain death was achieved. With increasing use of ECMO to support critically ill patients, physicians should become familiar with the challenges this technology has created when testing for apnea in the determination of brain death. In this case report, we showed that apnea testing can be done in patients on ECMO without the need for ancillary testing. The mainstay of performing apnea testing on these patients is decreasing the gas sweep rate to 0.5 -1 L/minute while maintaining the same blood flow rate.

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“…To assess brain death in these patients, apnea test can be performed without compromising oxygenation by decreasing (but not stopping) the sweep gas flow and increasing oxygen delivery through the membrane. 48,49 …”

Section: Spinellomentioning

confidence: 99%

Brain Death Determination

Spinello

2013

J Intensive Care Med

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In the United States, each year 1% to 2% of deaths are brain deaths. Considerable variation in the practice of determining brain death still remains, despite the publication of practice parameters in 1995 and an evidence-based guideline update in 2010. This review is intended to give bedside clinicians an overview of definition, the causes and pitfalls of misdiagnosing brain death, and a focus on the specifics of the brain death determination process.

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The Challenges with Brain Death Determination in Adult Patients on Extracorporeal Membrane Oxygenation

Abstract: Apnea testing is essential in the determination of brain death, but may not be employed in ECMO-treated adult patients. Apnea testing using the above protocol may assist in better decision making for adult ECMO patients at risk of brain death.

Cited by 55 publications

References 9 publications

First-year experience of a Brazilian tertiary medical center in supporting severely ill patients using extracorporeal membrane oxygenation

First-year experience of a Brazilian tertiary medical center in supporting severely ill patients using extracorporeal membrane oxygenation

Apnea Testing for the Determination of Brain Death in Patients Supported by Extracorporeal Membrane Oxygenation

Brain Death Determination

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