Challenges in patients supported with extracorporeal membrane oxygenation in Brazil

Extracorporeal membrane oxygenation is used as extracirculatory support for the care of patients with severe and reversible cardiac and/or respiratory failure. Neurological complications may be related to the procedure. Given the unfavorable neurological evolution and the need to perform a brain death protocol, the performance of an apnea test in this context remains a challenge. We report the use of an apnea test for the diagnosis of brain death post-cardiac surgery in a patient receiving venoarterial extracorporeal membrane oxygenation.

Section: Discussionmentioning

confidence: 99%

Apnea test for the diagnosis of brain death in a patient undergoing extracorporeal membrane oxygenation

Veiga

Silva

Sady

et al. 2020

“…Disconnection from the ventilator was performed in most of the reviewed cases, combined with supplemental oxygen therapy via catheter or T-piece. ( 10 , 12 - 14 , 16 , 17 , 22 , 23 ) The use of PEEP was also frequent. In these cases, an external valve attached to the endotracheal tube was instituted via a T-piece (CPAP 5 - 10cmH 2 O) or attached to the resuscitation bag (bag-valve or AMBU ® bag).…”

Section: Discussionmentioning

confidence: 99%

Apnea test for brain death diagnosis in adults on extracorporeal membrane oxygenation: a review

Sady¹,

Junqueira²,

Veiga³

et al. 2020

Among the potential complications of extracorporeal membrane oxygenation, neurological dysfunctions, including brain death, are not negligible. In Brazil, the diagnostic process of brain death is regulated by Federal Council of Medicine resolution 2,173 of 2017. Diagnostic tests for brain death include the apnea test, which assesses the presence of a ventilatory response to hypercapnic stimulus. However, gas exchange, including carbon dioxide removal, is maintained under extracorporeal membrane oxygenation, making the test challenging. In addition to the fact that the aforementioned resolution does not consider the specificities of the diagnostic process under extracorporeal membrane oxygenation, studies on the subject are scarce. This review aims to identify case studies (and/or case series) published in the PubMed ® and Cochrane databases describing the process of brain death diagnosis. A total of 17 publications (2011 - 2019) were identified. The practical strategies described were to provide pretest supplemental oxygenation via mechanical ventilation and extracorporeal membrane oxygenation (fraction of inspired oxygen = 1.0) and, at the beginning of the test, titrate the sweep flow (0.5 - 1.0L/minute) to minimize carbon dioxide removal. It is also recommended to increase blood flow and/or sweep flow in the presence of hypoxemia and/or hypotension, which may be combined with fluid infusion and/or the escalation of inotropic/vasoactive drugs. If the partial pressure of carbon dioxide threshold is not reached, repeating the test under supplementation of carbon dioxide exogenous to the circuit is an alternative. Last, in cases of venoarterial extracorporeal membrane oxygenation, to measure gas variation and exclude differential hypoxia, blood samples of the native and extracorporeal (post-oxygenator) circulations are recommended.

“…The cost associated with six months of QALY in the UK (£128,621.00) is very high for the Brazilian economy; however, this figure included the transport of 62 of 90 (69%) patients by air, regardless of ECMO use. In Brazil, patients using ECMO are transported by land ( 15 , 20 ) and air, ( 13 , 20 ) but these costs were not included in the current analysis.…”

Section: Discussionmentioning

confidence: 99%

The economic effect of extracorporeal membrane oxygenation to support adults with severe respiratory failure in Brazil: a hypothetical analysis

Park

Mendes

Zampieri

et al. 2014

Self Cite

Objective To analyze the cost-utility of using extracorporeal oxygenation for patients with severe acute respiratory distress syndrome in Brazil.Methods A decision tree was constructed using databases from previously published studies. Costs were taken from the average price paid by the Brazilian Unified Health System (Sistema Único de Saúde; SUS) over three months in 2011. Using the data of 10,000,000 simulated patients with predetermined outcomes and costs, an analysis was performed of the ratio between cost increase and years of life gained, adjusted for quality (cost-utility), with survival rates of 40 and 60% for patients using extracorporeal membrane oxygenation.Results The decision tree resulted in 16 outcomes with different life support techniques. With survival rates of 40 and 60%, respectively, the increased costs were R$=-301.00/-14.00, with a cost of R$=-30,913.00/-1,752.00 paid per six-month quality-adjusted life-year gained and R$=-2,386.00/-90.00 per quality-adjusted life-year gained until the end of life, when all patients with severe ARDS were analyzed. Analyzing only patients with severe hypoxemia (i.e., a ratio of partial oxygen pressure in the blood to the fraction of inspired oxygen <100mmHg), the increased cost was R$=-5,714.00/272.00, with a cost per six-month quality-adjusted life-year gained of R$=-9,521.00/293.00 and a cost of R$=-280.00/7.00 per quality-adjusted life-year gained.Conclusion The cost-utility ratio associated with the use of extracorporeal membrane oxygenation in Brazil is potentially acceptable according to this hypothetical study.