Enigma of apnea test for brain death on ECMO—an ongoing discussion—case study and review of literature

Sahu, Manoj Kumar; Vaswani, Prateek; Bipin, Chalattil; Singh, Sarvesh Pal; Hadda, Vijay

doi:10.1007/s12055-020-01008-w

Cited by 4 publications

(1 citation statement)

References 13 publications

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“…The data presented here highlight the di culties of assessing BD in the ECMO population, where neuroimaging can be challenging to obtain and AT di cult to perform. Due to altered gas exchange dynamics that may require prolonged time of apnea beyond the scheduled 8-10 minutes (although the mean time was 8 minutes in our center), 19,23 hemodynamic instability, 24 hypoxia, 15 and technical di culties in increasing CO 2 , 25 the AT may be challenging to perform, though it was the most common method for BD con rmation in 77% of ECMO patients in a large systematic review. 25 Several AT protocols for ECMO patients have been developed, using strategies such as oxygenation by T-piece 26 or endotracheal tube 10 and introduction of exogenous CO 2 .…”

Section: Discussionmentioning

confidence: 96%

Challenges in Brain Death Determination in Extracorporeal Membrane Oxygenation – A Single Center Experience

Zhao

Caturegli

Wilcox

et al. 2022

Preprint

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Background Conducting an apnea test (AT) in patients on extracorporeal membrane oxygenation (ECMO) support is challenging, leading to variable approaches for determining brain death (BD), also known as death by neurologic criteria (DNC). This study aims to describe the diagnostic criteria and barriers for DNC in a high-volume ECMO center with an emphasis on the role of AT. Methods A retrospective review of a prospective observational standardized neuromonitoring study was conducted in adult VA- and VV-ECMO patients at a tertiary center from June 2016-March 2022. Brain death was defined according to the 2010 American Academy of Neurology guidelines. AT for DNC in this study was performed in accordance with the 2020 Journal of the American Medical Association BD/DNC criteria recommendations for ECMO patients, including a period of pre-oxygenation, setting ECMO sweep to 0.5-1 L/min, and measuring serial blood gases. Results During the study period, 15 of 300 (5%) patients underwent testing for DNC. Eight (2.7%) ECMO patients (median age = 44 years, 75% male, and 50% VA-ECMO) were diagnosed with BD, six (75%) of whom were determined with AT. In the other two patients who did not undergo AT due to safety concerns, ancillary tests (TCD and EEG) were consistent with BD and the patients were declared BD on the basis of those findings. An additional seven (2.3%) patients (median age = 55 years, 71% male, and 86% VA ECMO) were noted to have absent brainstem reflexes but failed to complete determination of DNC as they underwent withdrawal of life-sustaining treatment due to family wishes before a full evaluation was completed. Six (86%) of these patients with unconfirmed BD had at least one ancillary test performed that were not consistent with BD despite either neurological exam findings and/or AT results supporting a BD diagnosis. In the seventh patient, although absent brainstem reflexes were noted on the neurological exam with explanatory findings on imaging, there was no AT or ancillary testing done. Conclusion AT was used safely and successfully in 6 of the 8 ECMO patients diagnosed with BD, though providers were more confident using AT with ancillary tests. AT was always consistent with the neurological exam and imaging findings suggesting BD. However, there are limitations to ancillary tests for BD assessments when used without AT and we recommend performing at least two ancillary tests to confirm brain death if AT cannot be performed or is inconclusive in ECMO patients.

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Section: Discussionmentioning

confidence: 96%

Challenges in Brain Death Determination in Extracorporeal Membrane Oxygenation – A Single Center Experience

Zhao

Caturegli

Wilcox

et al. 2022

Preprint

View full text Add to dashboard Cite

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Apnea Test on Extracorporeal Membrane Oxygenation: Step Forward with Carbon Dioxide

Nakip¹,

Kesici²,

Terzi³

et al. 2022

J Extra Corpor Technol

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Apnea test must be performed to confirm brain death in patients meet clinical criteria. But the increment of carbon dioxide is generally not achievable because of the diminished production of carbon dioxide and additional sweep in extra corporeal membrane oxygenation (ECMO). We report three children with congenital heart disease treated with ECMO and had brain death during follow-up. All met clinical criteria but apnea test cannot be achieved in classical way because of prolonged duration and hemodynamic compromise. Therefore, we used external carbon dioxide to achieve desired levels of oxygen and carbon dioxide safely. Because of the lack of protocols for pediatric patients on ECMO, apnea test with exogenous carbon dioxide may be a reliable and rapid test in such patients. Especially cardiac patients, in whom classical apnea test can cause rapid deterioration, exogenous carbon dioxide may serve as an alternative.

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Challenges in determining death by neurologic criteria in extracorporeal membrane oxygenation – A single center experience

et al. 2023

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Introduction Apnea test (AT) in patients on extracorporeal membrane oxygenation (ECMO) support is challenging, leading to variation in determining death by neurologic criteria (DNC). We aim to describe the diagnostic criteria and barriers for DNC in adults on ECMO in a tertiary care center. Methods A retrospective review of a prospective observational standardized neuromonitoring study was conducted in adult VA- and VV-ECMO patients at a tertiary center from June 2016 to March 2022. Brain death was defined according to the 2010 American Academy of Neurology guidelines and following the 2020 World Brain Death Project recommendations for performing AT in ECMO patients. Results Eight (2.7%) ECMO patients (median age = 44 years, 75% male, 50% VA-ECMO) met criteria for DNC, six (75%) of whom were determined with AT. In the other two patients who did not undergo AT due to safety concerns, ancillary tests (transcranial doppler and electroencephalography) were consistent with DNC. An additional seven (2.3%) patients (median age = 55 years, 71% male, 86% VA-ECMO) were noted to have absent brainstem reflexes but failed to complete determination of DNC as they underwent withdrawal of life-sustaining treatment (WLST) before a full evaluation was completed. In these patients, AT was never performed, and ancillary tests were inconsistent with either neurological exam findings and/or neuroimaging supporting DNC, or with each other. Conclusion AT was used safely and successfully in 6 of the 8 ECMO patients diagnosed with DNC and was always consistent with the neurological exam and imaging findings, as opposed to ancillary tests alone.

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Enigma of apnea test for brain death on ECMO—an ongoing discussion—case study and review of literature

Cited by 4 publications

References 13 publications

Challenges in Brain Death Determination in Extracorporeal Membrane Oxygenation – A Single Center Experience

Challenges in Brain Death Determination in Extracorporeal Membrane Oxygenation – A Single Center Experience

Apnea Test on Extracorporeal Membrane Oxygenation: Step Forward with Carbon Dioxide

Challenges in determining death by neurologic criteria in extracorporeal membrane oxygenation – A single center experience

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