Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Cardiovascular Surgery Intensive Care Unit, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
Perfusion. 2024 Sep;39(6):1238-1246. doi: 10.1177/02676591231187548. Epub 2023 Jun 30.
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.
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 guidelines and following the 2020 World Brain Death Project recommendations for performing AT in ECMO patients.
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.
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.
在体外膜肺氧合（ECMO）支持下的患者进行呼吸暂停试验（AT）具有挑战性，这导致了根据神经学标准确定死亡（DNC）的方法存在差异。我们旨在描述在一家三级护理中心的 ECMO 患者中，成人 DNC 的诊断标准和障碍。
对 2016 年 6 月至 2022 年 3 月期间在一家三级中心接受 VA 和 VV-ECMO 的成人 VA-和 VV-ECMO 患者进行了前瞻性观察性标准化神经监测研究的回顾性分析。脑死亡根据 2010 年指南定义，并遵循 2020 年世界脑死亡项目关于在 ECMO 患者中进行 AT 的建议。
8 名（2.7%）ECMO 患者（中位年龄=44 岁，75%男性，50%VA-ECMO）符合 DNC 标准，其中 6 名（75%）通过 AT 确定。在另外两名因安全问题未进行 AT 的患者中，辅助检查（经颅多普勒和脑电图）与 DNC 一致。另外 7 名（2.3%）患者（中位年龄=55 岁，71%男性，86%VA-ECMO）存在脑干反射缺失，但由于 WLST 前完成了完整评估，未能确定 DNC 而未完成 DNC 确定。在这些患者中，从未进行过 AT，辅助检查与神经学检查结果和/或支持 DNC 的神经影像学结果不一致，或彼此不一致。
在 8 名被诊断为 DNC 的 ECMO 患者中，有 6 名成功且安全地进行了 AT，并且始终与神经学检查和影像学发现一致，而不是仅与辅助检查一致。
