• Farid Salih, Johann Lambeck, Albrecht Günther, Caroline Ferse, Olaf Hoffmann, Konstantinos Dimitriadis, Andre Finn, Stephan A Brandt, Benjamin Hotter, Florian Masuhr, Stephan Schreiber, Florian Weissinger, Andrea Rocco, Hauke Schneider, Wolf-Dirk Niesen, and IGNITE study group.
• Dept. of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 13353 Berlin, Germany. Electronic address: farid.salih@charite.de.
• J Crit Care. 2024 Jun 1; 81: 154545154545.

PurposeThe Harlequin syndrome may occur in patients treated with venoarterial extracorporal membrane oxygenation (VA-ECMO), in whom blood from the left ventricle and the ECMO system supply different parts of the body with different paCO2-levels. The purpose of this study was to compare two variants of paCO2-analysis to account for the Harlequin syndrome during apnea testing (AT) in brain death (BD) determination.Materials And MethodsTwenty-seven patients (median age 48 years, 26-76 years; male n = 19) with VA-ECMO treatment were included who underwent BD determination. In variant 1, simultaneous arterial blood gas (ABG) samples were drawn from the right and the left radial artery. In variant 2, simultaneous ABG samples were drawn from the right radial artery and the postoxygenator ECMO circuit. Differences in paCO2-levels were analysed for both variants.ResultsAt the start of AT, median paCO2-difference between right and left radial artery (variant 1) was 0.90 mmHg (95%-confidence intervall [CI]: 0.7-1.3 mmHg). Median paCO2-difference between right radial artery and postoxygenator ECMO circuit (variant 2) was 3.3 mmHg (95%-CI: 1.5-6.0 mmHg) and thereby significantly higher compared to variant 1 (p = 0.001). At the end of AT, paCO2-difference according to variant 1 remained unchanged with 1.1 mmHg (95%-CI: 0.9-1.8 mmHg). In contrast, paCO2-difference according to variant 2 increased to 9.9 mmHg (95%-CI: 3.5-19.2 mmHg; p = 0.002).ConclusionsSimultaneous paCO2-analysis from right and left distal arterial lines is the method of choice to reduce the risk of adverse effects (e.g. severe respiratory acidosis) while performing AT in VA-ECMO patients during BD determination.Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.

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