Developing a Standard Method for Apnea Testing in the Determination of Brain Death for Patients on Venoarterial Extracorporeal Membrane Oxygenation

Jarrah, Rima J.; Ajizian, Samuel; Agarwal, Swati; Copus, Scott C.; Nakagawa, Thomas A.

doi:10.1097/pcc.0000000000000006

Cited by 28 publications

(25 citation statements)

References 10 publications

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“…There are five additional case reports that described, in varying degrees of detail, protocols used to perform apnea testing in eight patients. All involve maintaining patients on ECMO but decreasing the sweep flow rate in order to cause the PaCO 2 to rise above the target of 60 mm Hg after which patients were declared brain dead (Table 2) [21][22][23][24][25]. Jarrah and colleagues for example reported three pediatric patients on VA ECMO [21].…”

Section: The Apnea Test With Ecmomentioning

confidence: 99%

“…All involve maintaining patients on ECMO but decreasing the sweep flow rate in order to cause the PaCO 2 to rise above the target of 60 mm Hg after which patients were declared brain dead (Table 2) [21][22][23][24][25]. Jarrah and colleagues for example reported three pediatric patients on VA ECMO [21]. After preoxygenating by increasing the ECMO circuit FiO 2 to 100%, all were placed on CPAP with FiO 2 100% administered through a flow-inflating anesthesia bag connected to the endotracheal tube.…”

Section: The Apnea Test With Ecmomentioning

confidence: 99%

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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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Section: The Apnea Test With Ecmomentioning

confidence: 99%

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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“…Yet it is possible to manage the PaCO 2 level with adjustment of the sweep gas flow (SGF) and content (1). A large series was reported in adults (2), but pediatric data are limited (3,4). Here, we report a child with fulminant myocarditis, who was declared brain dead with a formal AT on extracorporeal membrane oxygenation (ECMO).…”

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confidence: 99%

Apnea Test on Extracorporeal Life Support System: Feasible and Needed

2018

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“…The substitution of the gas mixture flowing into the oxygenator with oxygen with a simultaneous reduction of the sweep gas flow rate in the oxygenator leads to hypercapnia without significant hypoxemia. Several reports have been published that indicate that the sweep gas flow rate in adults could be safely decreased to the approximately 0.5 L min -1 [11], while in small children, the flow value could be decreased to 0.1 L min -1 [12]. For practical reasons, the sweep gas flow rate in the oxygenator should be decreased to the lowest value that does not lead to a significant decrease in the arterial blood saturation.…”

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confidence: 99%

Możliwości wykonania próby bezdechu w czasie procedury rozpoznawania śmierci mózgu u chorych leczonych z użyciem utlenowania pozaustrojowego (ECMO)

Saucha

Sołek-Pastuszka²,

Bohatyrewicz³

et al. 2015

Anaesthesiol Intensive Ther

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Extracorporeal Membrane Oxygenation (ECMO) is a well-established method of support in patients with severe respiratory and/or circulatory failure. Unfortunately, this invasive method of treatment is associated with a high risk of neurological complications including brain death. Proper diagnosis of brain death is crucial for the termination of futile medical care. Currently, the legal system in Poland does not provide an accepted protocol for apnea tests for patients on ECMO support. Veno-arterial ECMO is particularly problematic in this regard because it provides both gas exchange and circulatory support. CO 2 elimination by ECMO prevents hypercapnia, which is required to perform an apnea test. Several authors have described a safe apnea test procedure in patients on ECMO. Maximal reduction of the sweep gas flow to the oxygenator should maintain an acceptable haemoglobin oxygenation level and reduce elimination of carbon dioxide. Hypercapnia achieved via this method should allow an apnea test to be conducted in the typical manner. In the case of profound desaturation and an inadequate increase in the arterial CO 2 concentration, the sweep gas flow rate may be increased to obtain the desired oxygenation level, and exogenous carbon dioxide may be added to achieve a target carbon dioxide level. Incorporation of an apnea test for ECMO patients is planned in the next edition of the Polish guidelines on the determination of brain death.

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Developing a Standard Method for Apnea Testing in the Determination of Brain Death for Patients on Venoarterial Extracorporeal Membrane Oxygenation

Cited by 28 publications

References 10 publications

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

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

Apnea Test on Extracorporeal Life Support System: Feasible and Needed

Możliwości wykonania próby bezdechu w czasie procedury rozpoznawania śmierci mózgu u chorych leczonych z użyciem utlenowania pozaustrojowego (ECMO)

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