P062: BRAIN DEATH DETERMINATION ON VENO-VENOUS EXTRACORPOREAL MEMBRANE OXYGENATOR
Emily Chung, DO; David McDougal, DO; Victor Iturbides, MD; Kendall Regional Medical Center
Introduction: A 31-year-old female was transferred for further management of veno-venous extracorporeal membrane oxygenation machine (ECMO). The patient presented for worsening abdominal pain due to tubo-ovarian abscess, which lead to having a left salpingectomy done. She later developed acute abdomen syndrome and was brought back to the operating room. She continued to decompensate and developed worsening acute hypoxic respiratory failure requiring intubation, and later was determined to be a candidate for ECMO.
Methods: On arrival to receiving hospital, patient was on propofol, fentanyl, and midazolam drips. On physical exam, pupils were noted to be fixed and dilated. Sedation was held for one hour. On re-evaluation, pupils remained dilated and nonreactive. A Stroke alert was called and a computerized tomography scan of her brain was done. Imaging showed bilateral cerebral hemorrhages and diffuse cerebral edema. Following the results, there was high suspicion of brain death and further auxiliary testing were ordered.
Results: A nuclear medicine brain scan and electroencephalogram were performed and were compatible with brain death. The patient was optimized and laboratory values were within normal limits. The patient was taken off of all paralytic and sedation medication for over twenty-four hours. The American Academy of Neurology guidelines for declaration of brain death was used with some modifications to the apnea test as patient was on ECMO. On physical exam, the patient demonstrated lack of brainstem function. For the apnea test, the patient was preoxygenated and removed from the ventilator with a nasal cannula placed in the endotracheal tube. The sweep was brought down to 0L with the FiO2 at 1.0. During the test, no spontaneous breaths were noted. The repeat ABG was taken and the patient was declared brain dead.
Discussion/Conclusion: The usage of ECMO has grown in popularity nationally. With increased usage comes increased incidence of suspected brain death patients. As of current, there are not any national guidelines on brain death on ECMO. However, in some academic centers, they implemented institutional guidelines on how to proceed. Those guidelines and resources are not widely accessible to community hospitals. There needs to be more guidance on the process of brain death pronouncement while on ECMO.