Developing a standard method for apnea testing in the determination of brain death for patients on venoarterial extracorporeal membrane oxygenation: A pediatric case series

Objective: The revised guidelines for the determination of brain death in infants and children stress that apnea testing is an integral component in determining brain death based on clinical criteria. Unfortunately, these guidelines provide no process for apnea testing during the determination of brain death in patients supported on venoarterial extracorporeal membrane oxygenation. We review three pediatric patients supported on venoarterial extracorporeal membrane oxygenation who underwent apnea testing during their brain death evaluation. This is the only published report to elucidate a reliable, successful method for apnea testing in pediatric patients supported on venoarterial extracorporeal membrane oxygenation. Design: Retrospective case series. Setting: Two tertiary care PICUs in university teaching hospitals. Patients: Three pediatric patients supported by venoarterial extracorporeal membrane oxygenation after cardiopulmonary arrest. Interventions: After neurologic examinations demonstrated cessation of brain function in accordance with current pediatric brain death guidelines, apnea testing was performed on each child while supported on venoarterial extracorporeal membrane oxygenation. Measurements and main results: In two of the three cases, the patients remained hemodynamically stable with normal oxygen saturations as venoarterial extracorporeal membrane oxygenation sweep gas was weaned and apnea testing was undertaken. Apnea testing demonstrating no respiratory effort was successfully completed in these two cases. The third patient became hemodynamically unstable, invalidating the apnea test. Conclusions: Apnea testing on venoarterial extracorporeal membrane oxygenation can be successfully undertaken in the evaluation of brain death. We provide a suggested protocol for apnea testing while on venoarterial extracorporeal membrane oxygenation that is consistent with the updated pediatric brain death guidelines. This is the only published report to elucidate a reliable, successful method for apnea testing in pediatric patients supported on venoarterial extracorporeal membrane oxygenation.