Brain Death Determination During VA-ECMO After Pediatric Cardiac Surgery: A Case-Based Analysis of the 2023 Unified Consensus.
Nurgül Yurtseven, Emine Hekim Yilmaz, Suna Yaka et al.
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Case in brief
A pediatric patient on venoarterial ECMO after cardiac arrest underwent brain death/death by neurologic criteria (BD/DNC) assessment. During apnea testing, sweep gas flow was reduced in a controlled manner with serial arterial blood gas monitoring. Carbon dioxide tension rose from 43.1 to 74.5 mm Hg without spontaneous respiratory effort, and arterial pH fell to 7.19, meeting the acidemia requirement later introduced in the 2023 consensus guideline. The clinical examination met prerequisites under both the 2011 pediatric guideline and the updated framework; retrospective review found the original diagnosis concordant with the 2023 criteria.
What made this case unusual
The case demonstrates that an ECMO-adapted apnea test can meet the 2023 guideline’s mandatory pH threshold despite extracorporeal carbon dioxide clearance, with no respiratory effort observed.
Diagnostic / clinical pearl
During BD/DNC assessment on ECMO, controlled sweep-gas reduction with serial blood gas monitoring can document the required carbon dioxide rise and acidemia; assess the full physiologic criteria rather than relying on carbon dioxide tension alone.
Why it matters
The case provides a practical example of applying the 2023 consensus criteria to a pediatric patient on venoarterial ECMO, while supporting feasibility only when physiologic conditions are carefully optimized.