title: Developing a standard method for apnea testing in the determination of brain death for patients on venoarterial extracorporeal membrane oxygenation: a pediatric case series.
abstract: 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.
  
  
  METHODS
  Retrospective case series.
  
  
  METHODS
  Two tertiary care PICUs in university teaching hospitals.
  
  
  METHODS
  Three pediatric patients supported by venoarterial extracorporeal membrane oxygenation after cardiopulmonary arrest.
  
  
  METHODS
  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.
  
  
  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.
authors.affiliation: 1Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC. 2Department of Pediatrics, Section of Pediatric Critical Care, Inova Fairfax Hospital for Children, Falls Church, VA. 3Department of Respiratory Care, Wake Forest Baptist Health, Brenner Children's Hospital, Winston-Salem, NC.
authors.forename: Rima J
authors.initials: RJ
authors.lastname: Jarrah
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Ajizian
authors.forename: Swati
authors.initials: S
authors.lastname: Agarwal
authors.forename: Scott C
authors.initials: SC
authors.lastname: Copus
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Nakagawa
mesh_terms: D000293:Adolescent; D001049:Apnea / Q000175:diagnosis*; D001926:Brain Death / Q000175:diagnosis*; D002648:Child; D002675:Child, Preschool; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D006785:Hospitals, University; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D010372:Pediatrics; D012189:Retrospective Studies