Ventilator-Delivered Continuous Positive Airway Pressure for Apnea Test in the Diagnosis of Brain Death in Patient With Extremely Poor Baseline Lung Function—Case Report
01 Sep 2016-Vol. 48, Iss: 7, pp 2471-2472
TL;DR: Ventilator-delivered CPAP for AT may be a valuable alternative to the classic oxygen insufflation method for the BD diagnosis procedure in patients with severe lung injury and poor baseline oxygenation.
Abstract: Polish brain death (BD) criteria established in 2007 are currently under review and therefore all reports about any problems noticed during diagnostic attempts are being carefully analyzed. According to information from intensive care units, patients with poor baseline lung function often do not tolerate ventilator disconnection during the apnea test (AT) despite previous preoxygenation and catheter O2 insufflation. Abortion of AT because of decrease of saturation as measured by pulse oximetry is quite common. To solve this problem, implementation of continuous positive airway pressure (CPAP) with 100% O2 was proposed as an option for newly developed guidelines. Before implementation of CPAP for AT we verified it by means of a multicenter trial in a group of 51 patients with various lung function. In one case, in a patient with baseline PaO2 of 83 mm Hg during ventilation with 100% oxygen, we used the CPAP option for AT and successfully completed BD diagnosis. In conclusion, ventilator-delivered CPAP for AT may be a valuable alternative to the classic oxygen insufflation method for the BD diagnosis procedure in patients with severe lung injury and poor baseline oxygenation.
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TL;DR: Both methods of O2 supplementation are associated with similar changes in arterial PO2 and PCO2 and performance of ABGs at regular intervals shortens apnea test duration and may avoid excessive pH reduction and consequent hemodynamic effects.
Abstract: Apnea testing is an essential step in the clinical diagnosis of brain death. Current international guidelines recommend placement of an oxygen (O2) insufflation catheter into the endotracheal tube to prevent hypoxemia, but use of a continuous positive airway pressure (CPAP) valve may be more effective at limiting arterial partial pressure of O2 (PO2) reduction. We performed a multicenter study assessing consecutive apnea tests in 14 intensive care units (ICUs) in two cities utilizing differing protocols. In one city, O2 catheters are placed and arterial blood gases (ABGs) performed at intervals determined by the attending physician. In the other city, a resuscitation bag with CPAP valve is attached to the endotracheal tube, and ABGs performed every 3–5 min. We assessed arterial PO2, partial pressure of carbon dioxide (PCO2), pH, and blood pressure at the beginning and termination of each apnea test. Thirty-six apnea tests were performed using an O2 catheter and 50 with a CPAP valve. One test per group was aborted because of physiological instability. There were no significant differences in the degree of PO2 reduction (−59 vs. −32 mmHg, p = 0.72), rate of PCO2 rise (3.2 vs. 3.9 mmHg per min, p = 0.22), or pH decline (−0.02 vs. −0.03 per min, p = 0.06). Performance of ABGs at regular intervals was associated with shorter test duration (10 vs. 7 min, p < 0.0001), smaller PCO2 rise (30 vs. 26 mmHg, p = 0.0007), and less pH reduction (−0.20 vs. −0.17, p = 0.0012). Lower pH at completion of the apnea test was associated with greater blood pressure decline (p = 0.006). Both methods of O2 supplementation are associated with similar changes in arterial PO2 and PCO2. Performance of ABGs at regular intervals shortens apnea test duration and may avoid excessive pH reduction and consequent hemodynamic effects.
11 citations
Cites background from "Ventilator-Delivered Continuous Pos..."
...Use of a resuscitation bag with CPAP valve has been reported in a relatively large clinical series to be effective at attenuating hypoxemia [19]....
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TL;DR: Although MAT, which was invented to maintain PEEP, was not efficient for all brain-dead patients, it could be helpful in selected patient groups, such as overweight patients or those who had hypoxic injury due to hanging.
7 citations
Cites methods or result from "Ventilator-Delivered Continuous Pos..."
...Other previous studies also conducted apnea tests for 10 minutes because such length was a standard recommendation.([6,19]) However, as mentioned above, we checked ABGAs after 2 or 3 minutes, and then each minute from the start of the...
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...Unlike previous studies,([6,18,19]) these unexpected results were thought to result from shorter durations apnea tests....
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...We had expected that the reduction in PaO2 or frequency of severe hypoxemiawould be smaller in theMATgroup than in the CAT group, as in previous studies.([6,18,19]) However, there were no significant differences in PaO2 or frequency of severe hypoxemia....
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06 Jan 2017
TL;DR: This review presents the international recommendations of potential organ donors management, which it is hoped can be adopted in institutional protocols to optimize the management of potential donors in Colombia, thus increasing transplants and meeting the needs of the patients.
Abstract: In many cases organ transplantation is the only therapeutic option for patients with terminal essential organ diseases; however, there is an imbalance between the number of organs available and the number of potential receptors for transplants worldwide. Patients with brain death are the main source of organs for transplantation. Promoting early recognition of measures that prevent damage of organs in brain death organ donors is essential for appropriate clinical management. In this framework, it is known that aggressive clinical management of those potential organ donors using standardized protocols are associated with a greater number of transplanted organs and the reduction of the loss of potential donors by cardiac arrest. Colombia is a country with low donation rates and high transplant needs, with a waiting list that increases exponentially each year. In this review we present the international recommendations of potential organ donors management, which we hope can be adopted in institutional protocols to optimize the management of potential donors in Colombia, thus increasing transplants and meeting the needs of the patients.
6 citations
References
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TL;DR: Apnea testing in brain death determination may result in cardiovascular complications, and significantly more complications were observed in apnea tests with inadequate precautions, particularly in apneic oxygenation tests without adequate preoxygenation.
Abstract: Apnea testing in brain death determination may result in cardiovascular complications. Hypotension occurred in 24% and cardiac arrhythmias occurred in <1% of the 145 apneic oxygenation procedures. Complications were noted in only 15% of apnea tests performed without any predisposing factors. Significantly more complications (39%) were observed in apnea tests with inadequate precautions, particularly in apnea tests without adequate preoxygenation (50%).
117 citations
"Ventilator-Delivered Continuous Pos..." refers background in this paper
...The test may be potentially harmful; some serious complications, including pneumothorax, severe hypoxemia, hemodynamic instability, and even cardiac arrest, have been reported [9,10]....
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Journal Article•
TL;DR: Complications during the AT are more common than reported and limit organ procurement for transplantation and guidelines for performing the AT should be followed in order to avoid clinical complications.
Abstract: evaluate complications or difficulties related to this procedure. Objective: To analyze medical problems associated with the apnea test. Methods and Patients: We analyzed clinical features, potential risk conditions, and problems in 129 brain dead patients during the apnea test. The diagnosis of brain death was made according to the American Academy of Neurology recommendations. Results: Clinical problems during the apnea test were detected in more than two thirds of patients, including: arterial hypotension (12%), acidosis (68%), and hypoxemia (23%). Four patients developed major complications, including: pneumothorax, cardiac arrest, bradycardia, atrial fibrillation and myocardial infarction. Conclusion: The apnea test is not an innocuous procedure. Complications during the AT are more common than reported and limit organ procurement for transplantation. Guidelines for performing the AT should be followed in order to avoid clinical complications.
48 citations
"Ventilator-Delivered Continuous Pos..." refers background in this paper
...The test may be potentially harmful; some serious complications, including pneumothorax, severe hypoxemia, hemodynamic instability, and even cardiac arrest, have been reported [9,10]....
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01 Dec 2010
TL;DR: CTA and CTP seem to be promising radiological examinations for the diagnosis of BD and may be noninvasive alternatives to conventional cerebral angiography, and to the other instrumental confirmatory tests, that are unavailable or inadequate.
Abstract: Introduction According to Polish brain death (BD) criteria, instrumental confirmatory tests should be used in certain clinical situations, particularly any case for which clinical examinations seem inadequate. Electrophysiological tests are often unavailable. Therefore, cerebral perfusion testing is the method of choice with four-vessel digital subtraction angiography (DSA), the gold standard. Unfortunately, DSA is an expensive and invasive examination that requires an experienced neuroradiologist and the availability of an angiography suite. Recently, multirow computed tomographic devices became available, even in smaller hospitals in Poland. Despite this fact, computed tomographic angiography (CTA) and computed tomographic perfusion (CTP) are not accepted in BD diagnosis protocols in Poland because of limited experience and a lack of widely accepted criteria. In this situation, we started a multicenter trial to determine the accuracy of CTA and CTP to confirm BD. Methods We examined 24 patients who fulfilled standard clinical BD criteria. We recognized the absence of brain perfusion in CTA examination following the criteria proposed by the French Society of Neuroradiology, namely, the absence of opacification of M4 middle cerebral artery segments (M4-MCA) and of deep cerebral veins. Results In all of our patients, CTA showed absence of opacification of M4 segments and of deep cerebral veins. In addition, three patients had CTA showing weak opacification of A2 segments of the anterior cerebral artery (A2-ACA) and M2 or M3-MCA. Opacification of the basilar artery or of the posterior cerebral arteries was not noted in any case. In all patients, CTP revealed zero values of regional cerebral blood volume and regional cerebral blood flow. Conventional angiography confirmed cerebral circulatory arrest in all 24 cases. Conclusion CTA and CTP seem to be promising radiological examinations for the diagnosis of BD. They may be noninvasive alternatives to conventional cerebral angiography, and to the other instrumental confirmatory tests, that are unavailable or inadequate.
34 citations
"Ventilator-Delivered Continuous Pos..." refers methods in this paper
...Possible implementation of newly validated computerized tomographic angiography was accepted by Polish radiology authorities [4,5]....
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TL;DR: A recruitment maneuver and CPAP valve may be used in severe ARDS for safe apnea testing in brain death determination in a 42-year-old man with a subarachnoid hemorrhage.
Abstract: Introduction
A 42-year-old man with a subarachnoid hemorrhage complicated by anoxic brain injury, respiratory failure requiring mechanical ventilation, and severe acute respiratory distress syndrome (ARDS) presented a clinical conundrum for safe apnea testing in brain death determination due to profound hypoxemia.
19 citations
"Ventilator-Delivered Continuous Pos..." refers background in this paper
...ion Proceedings, 48, 2471e2472 (2016) serious lung damage, very fast desaturation have been observed [11]....
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TL;DR: In the case of profound desaturation and an inadequate increase in the arterial CO₂ concentration, the sweep gas flow rate may be increased to obtain the desired oxygenation level, and exogenous carbon dioxide may be added to achieve a target carbon dioxide level.
Abstract: Extracorporeal Membrane Oxygenation (ECMO) is a well-established method of support in patients with severe respiratory and/or circulatory failure. Unfortunately, this invasive method of treatment is associated with a high risk of neurological complications including brain death. Proper diagnosis of brain death is crucial for the termination of futile medical care. Currently, the legal system in Poland does not provide an accepted protocol for apnea tests for patients on ECMO support. Veno-arterial ECMO is particularly problematic in this regard because it provides both gas exchange and circulatory support. CO₂ elimination by ECMO prevents hypercapnia, which is required to perform an apnea test. Several authors have described a safe apnea test procedure in patients on ECMO. Maximal reduction of the sweep gas flow to the oxygenator should maintain an acceptable haemoglobin oxygenation level and reduce elimination of carbon dioxide. Hypercapnia achieved via this method should allow an apnea test to be conducted in the typical manner. In the case of profound desaturation and an inadequate increase in the arterial CO₂ concentration, the sweep gas flow rate may be increased to obtain the desired oxygenation level, and exogenous carbon dioxide may be added to achieve a target carbon dioxide level. Incorporation of an apnea test for ECMO patients is planned in the next edition of the Polish guidelines on the determination of brain death.
19 citations
"Ventilator-Delivered Continuous Pos..." refers background in this paper
...In particular, practical aspects of clinical examinations, including apnea test, in patients with poor lung function or on extracorporeal mechanical oxygenation support have been extensively discussed [2,3]....
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