Division of Neurology, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010, USA.
Division of Critical Care Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010, USA.
Neurocrit Care. 2019 Oct;31(2):304-311. doi: 10.1007/s12028-019-00700-z.
BACKGROUND/OBJECTIVE: Children supported by extracorporeal membrane oxygenation (ECMO) are at risk of catastrophic neurologic injury and brain death. Timely determination of brain death is important for minimizing psychological distress for families, resource allocation, and organ donation. Reports of successful determination of brain death in pediatric patients supported by ECMO are limited. The determination of brain death by clinical criteria requires apnea testing, which has historically been viewed as challenging in patients supported by ECMO. We report eight pediatric patients who underwent a total of 14 brain death examinations, including apnea testing, while supported by veno-arterial ECMO (VA-ECMO), resulting in six cases of clinical determination of brain death.
We performed a retrospective review of the medical records of pediatric patients who underwent brain death examination while supported by VA-ECMO between 2010 and 2018 at a single tertiary care children's hospital.
Eight patients underwent brain death examination, including apnea testing, while supported by VA-ECMO. Six patients met criteria for brain death, while two had withdrawal of technical support after the first examination. During the majority of apnea tests (n = 13/14), the ECMO circuit was modified to achieve hypercarbia while maintaining oxygenation and hemodynamic stability. The sweep flow was decreased prior to apnea testing in ten brain death examinations, carbon dioxide was added to the circuit during three examinations, and ECMO pump flows were increased in response to hypotension during two examinations.
Clinical determination of brain death, including apnea testing, can be performed in pediatric patients supported by ECMO. The ECMO circuit can be effectively modified during apnea testing to achieve a timely rise in carbon dioxide while maintaining oxygenation and hemodynamic stability.
背景/目的：接受体外膜肺氧合（ECMO）支持的儿童有发生灾难性神经损伤和脑死亡的风险。及时确定脑死亡对于最大限度地减少家庭的心理困扰、资源分配和器官捐献都很重要。关于 ECMO 支持的儿科患者成功确定脑死亡的报告有限。通过临床标准确定脑死亡需要进行呼吸暂停测试，但在 ECMO 支持的患者中，该测试历来被认为具有挑战性。我们报告了 8 例儿科患者共进行了 14 次脑死亡检查，包括呼吸暂停测试，结果有 6 例临床确定脑死亡。
我们对 2010 年至 2018 年期间在一家三级儿童保健医院接受 ECMO 支持下脑死亡检查的儿科患者的病历进行了回顾性分析。
8 例患者在接受 VA-ECMO 支持的情况下进行了脑死亡检查，包括呼吸暂停测试。6 例患者符合脑死亡标准，而 2 例患者在第一次检查后停止了技术支持。在大多数呼吸暂停测试（n=13/14）中，ECMO 回路被修改以在维持氧合和血液动力学稳定的同时实现高碳酸血症。在 10 次脑死亡检查中，在进行呼吸暂停测试前降低了扫流，在 3 次检查中向回路中添加了二氧化碳，在 2 次检查中根据低血压增加了 ECMO 泵流量。
可以在 ECMO 支持的儿科患者中进行脑死亡的临床确定，包括呼吸暂停测试。在呼吸暂停测试期间，可以有效地修改 ECMO 回路以实现二氧化碳的及时升高，同时维持氧合和血液动力学稳定。
