title: The challenges with brain death determination in adult patients on extracorporeal membrane oxygenation.
abstract: BACKGROUND
  To identify a reliable method of performing apnea testing as part of brain death determination in adult patients who develop loss of brainstem reflexes while receiving extracorporeal membrane oxygenation (ECMO). ECMO provides extracirculatory support to patients in cardiorespiratory failure who would otherwise be expected to die. Many studies have reported brain death as a potential complication of adult ECMO, but none have cited how apnea testing was performed in these patients.
  
  
  METHODS
  This retrospective review identified adults 15 years or older treated with ECMO at our institution (2002-2010) and the method of determination of brain death when complete loss of brainstem reflexes occurred.
  
  
  RESULTS
  Loss of all brainstem reflexes was identified in three cases (3/87, 3.4%). The apnea test was not performed since it was deemed "difficult," leading to withdrawal of ECMO and intensive care. Ancillary tests such as cerebral flow studies were not used because they may not document absent cerebral arterial flow due to the ischemic nature of the injury. We propose the use of an oxygenated apnea test on ECMO using continuous positive airway pressure (CPAP) through the ventilator or anesthesia bag, with an inline manometer and an end tidal CO(2) device.
  
  
  CONCLUSIONS
  Apnea testing is essential in the determination of brain death, but may not be employed in ECMO-treated adult patients. Apnea testing using the above protocol may assist in better decision making for adult ECMO patients at risk of brain death.
authors.affiliation: Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Muralidharan.Rajanandini@mayo.edu
authors.forename: RajaNandini
authors.initials: R
authors.lastname: Muralidharan
authors.forename: Farrah J
authors.initials: FJ
authors.lastname: Mateen
authors.forename: Russell T
authors.initials: RT
authors.lastname: Shinohara
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Schears
authors.forename: Eelco F M
authors.initials: EF
authors.lastname: Wijdicks
mesh_terms: D000328:Adult; D000368:Aged; D001049:Apnea / Q000503:physiopathology*; D001926:Brain Death / Q000175:diagnosis* / Q000503:physiopathology; D001933:Brain Stem / Q000503:physiopathology; D015331:Cohort Studies; D045422:Continuous Positive Airway Pressure; D003661:Decision Support Techniques; D004569:Electroencephalography; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006801:Humans; D008020:Life Support Care; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D012021:Reflex, Abnormal / Q000502:physiology; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed