Neurointensivist Cooper University Hospital Camden, United States
Introduction: Currently there is no global protocol or consensus on neuromonitoring, sedation or brain death (BD) testing practices for patients undergoing extracorporeal membrane oxygenation (ECMO), and we suspect there is a wide variation in practice and testing.
Methods: The study was designed as a voluntary closed web-based survey consisting of 22 questions targeting healthcare providers globally who care for patients undergoing V-V and V-A ECMO.
Results: 35 practitioners responded, a majority (90.9%) of whom practice in an academic teaching hospital. The most common neuromonitoring techniques were near-infrared spectroscopy (7/32, 21.8%), electroencephalography (EEG) (12/32, 37%) and clinical exam only (10/32, 31%). First-line sedatives included opioids (23/32, 29%), propofol (18/32, 23%), dexmedetomidine (17/32, 21%), benzodiazepines (15/32, 19%), and ketamine (6/32, 8%). Hydromorphone was the most common analgesic used (5/10, 50%). Absence of agitation and pain were the most common reasons to wean sedation (4/6, 66.7%) and analgesics (3/7, 42.8%) respectively. A majority of respondents stated 0-20% (17/32, 53%) or 21-60% (13/32, 40.6%) of their patients received NMBD during ECMO. A majority of respondents either did not have or were not sure if they had (20/33, 60.6%) a standardized institutional protocol for BD testing. BD testing was most commonly performed by intensivists irrespective of specialty (22/33, 66.7%). Of the 29 practitioners that perform BD testing, 15 (52%) perform testing off the ventilator, while 14 (48%) perform it on the ventilator. 18/33 (54%) providers perform the apnea test for both V-V and V-A ECMO patients compared to 10/33 (30%) practitioners who do not perform the apnea test on any patients. Most respondents titrated baseline sweep flow to meet a CO2 goal instead of a particular target (21/33, 63.6%). Most commonly used ancillary tests for BD determination were nuclear medicine perfusion study (12/32, 37%), EEG at (9/32, 28%), and CT angiography (6/32, 19%).
Conclusions: Our survey indicates there is a wide variation in neuromonitoring techniques, sedation use and BD testing in patients that undergo V-A and V-V ECMO globally. This informs current knowledge gaps that can be addressed by prospective research and guidelines.
