Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
Heart Lung Circ. 2022 Feb;31(2):239-245. doi: 10.1016/j.hlc.2021.05.100. Epub 2021 Jun 29.
To describe apnoea test (AT) and ancillary study performance for brain death (BD) determination among patients undergoing short-term mechanical circulatory support (MCS) devices, including extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP).
We retrospectively analysed data regarding use of AT and ancillary study in consecutive adult patients who were diagnosed with BD while on MCS devices (including ECMO and IABP) over a 10-year period.
Out of 140 patients, eight were on MCS devices at the time of BD (four ECMO, two ECMO and IABP, two IABP). The most common aetiology of BD was hypoxic ischaemic brain injury (6/8, 75%). In four patients (50%), the AT was not attempted because of haemodynamic instability and ECMO; in the remaining four (50%), both AT and ancillary studies were used. In three patients on ECMO, AT was performed by reducing the ECMO sweep flow rate to a range 0.5-2.7 L/min in order to achieve hypercarbia. One patient underwent AT while on IABP which was complicated by hypotension. All patients underwent ancillary tests, most commonly transcranial Doppler ultrasonography (TCD) (7/8, 88%); among those, cerebral circulatory arrest was confirmed in six of seven patients (86%), all of whom had left ventricular ejection fracture (LVEF) ≥20% and/or were supported with IABP.
There are multiple uncertainties regarding BD diagnosis while on MCS, prompting the need for ancillary studies in most patients. Our study shows that TCD can be used to support BD diagnosis in patients on ECMO who have sufficient cardiac contractility and/or IABP to produce pulsatile flow. TCD use in ECMO patients low LVEF needs further study.
描述在接受短期机械循环支持（MCS）设备治疗的患者中进行脑死亡（BD）测定的呼吸暂停试验（AT）和辅助研究表现，包括体外膜氧合（ECMO）和主动脉内球囊泵（IABP）。
我们回顾性分析了 10 年来连续接受 MCS 设备（包括 ECMO 和 IABP）治疗的成人患者使用 AT 和辅助研究的数据，这些患者被诊断为 BD。
在 140 名患者中，有 8 名在 BD 时使用 MCS 设备（4 名 ECMO，2 名 ECMO 和 IABP，2 名 IABP）。BD 的最常见病因是缺氧缺血性脑损伤（6/8，75%）。由于血流动力学不稳定和 ECMO，有 4 名患者（50%）未进行 AT；在其余 4 名患者（50%）中，均使用了 AT 和辅助研究。在 3 名接受 ECMO 的患者中，通过将 ECMO 扫流率降低至 0.5-2.7 L/min 范围来进行 AT，以实现高碳酸血症。1 名接受 IABP 的患者进行了 AT，该患者出现低血压。所有患者均进行了辅助检查，最常见的是经颅多普勒超声检查（TCD）（7/8，88%）；在这 7 名患者中，有 6 名（86%）确认存在脑循环停止，所有患者的左心室射血分数（LVEF）≥20%和/或接受 IABP 支持。
在 MCS 期间，BD 诊断存在多种不确定性，这促使大多数患者需要进行辅助检查。我们的研究表明，在具有足够心肌收缩力和/或 IABP 以产生搏动性血流的接受 ECMO 的患者中，可以使用 TCD 来支持 BD 诊断。TCD 在 ECMO 患者中低 LVEF 的应用需要进一步研究。
