What are the criteria to withdraw Extracorporeal Membrane Oxygenation (ECMO) support in a brain dead patient?

Criteria for Withdrawing ECMO Support in Brain Dead Patients

Brain death determination in ECMO patients requires a multimodality approach including clinical examination, neuroimaging, and an apnea test, with cerebral angiogram or nuclear scan as preferred ancillary tests when apnea testing is challenging due to hemodynamic instability. 1

Brain Death Determination Process

Primary Criteria

• Devastating brain injury on imaging: Confirm presence of severe, irreversible brain damage 1
• Neurological examination: Document absence of brainstem reflexes and cerebral function 1
• Apnea test: Modified for ECMO patients by either:
  • Reducing sweep gas flow
  • Adding exogenous carbon dioxide 1

Alternative Tests When Apnea Testing Is Not Feasible

• Cerebral angiogram: First-line ancillary test when hemodynamic/cardiopulmonary instability prevents apnea testing 1
• Radionuclide brain scan: Alternative nuclear medicine approach to confirm absence of cerebral blood flow 1

Legal and Procedural Requirements

• Follow official recommendations, guidelines, and laws specific to your country/jurisdiction 1
• Exclude confounding factors that could mimic brain death:
  • Sedative medications
  • Neuromuscular blockade
  • Severe metabolic disturbances
  • Hypothermia 1

Withdrawal Process After Brain Death Confirmation

Pre-Withdrawal Planning

• Conduct structured family meetings to prepare for withdrawal 1
• Involve ethics consultation (ideally within 72 hours of ECMO cannulation) 1
• Document patient's previously expressed wishes regarding end-of-life care 1

Technical Aspects of Withdrawal

• Implement symptom management protocols 1
• Plan technical circuit management for discontinuation 1
• Provide bereavement support for family 1
• Consider organ donation potential in appropriate cases 2

Important Considerations and Pitfalls

Avoid Common Errors

• Never use a single factor/tool (e.g., brain imaging alone) as the sole indicator for brain death determination 1
• Do not rush withdrawal decisions in patients who are not-yet brain-dead or still undergoing testing 2
• Recognize that neurological prognostication in ECMO patients is challenging with limited data 1

Family Support

• Assign a dedicated team member to remain with family during the process 1
• Provide clear, compassionate communication about brain death determination 1
• Acknowledge that families of ECMO patients experience significant anxiety, depression, and post-traumatic stress disorder 1

Special Considerations

• For patients initially placed on ECMO as a "bridge to decision" rather than with a clear liberation strategy, withdrawal decisions are particularly complex 3
• Presence of brain injury is associated with fewer palliative care visits and may lead to more straightforward withdrawal decisions 4
• Hispanic and white patients may be more likely to be withdrawn from life support than African American patients, suggesting potential cultural or social factors in decision-making 5

Brain death determination in ECMO patients requires careful adherence to established protocols with modifications specific to the extracorporeal support. The withdrawal process should be structured, compassionate, and involve multidisciplinary input with particular attention to family support throughout.