Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2019 Jan-Mar;31(1):106-110.
doi: 10.5935/0103-507X.20190015.

Optimization of conditions for apnea testing in a hypoxemic brain dead patient

[Article in Portuguese, English]
Bárbara Vieira Carneiro  1 , Guilherme Henrique Garcia  1 , Larissa Padrão Isensee  2 , Bruno Adler Maccagnan Pinheiro Besen  1
Affiliations
Case Reports

Optimization of conditions for apnea testing in a hypoxemic brain dead patient

[Article in Portuguese, English]
Bárbara Vieira Carneiro et al. Rev Bras Ter Intensiva. 2019 Jan-Mar.

Abstract
in English, Portuguese

We report the case of a patient in whom brain death was suspected and associated with atelectasis and moderate to severe hypoxemia even though the patient was subjected to protective ventilation, a closed tracheal suction system, positive end-expiratory pressure, and recruitment maneuvers. Faced with the failure to obtain an adequate partial pressure of oxygen for the apnea test, we elected to place the patient in a prone position, use higher positive end-expiratory pressure, perform a new recruitment maneuver, and ventilate with a higher tidal volume (8mL/kg) without exceeding the plateau pressure of 30cmH2O. The apnea test was performed with the patient in a prone position, with continuous positive airway pressure coupled with a T-piece. The delay in diagnosis was 10 hours, and organ donation was not possible due to circulatory arrest. This report demonstrates the difficulties in obtaining higher levels of the partial pressure of oxygen for the apnea test. The delays in the diagnosis of brain death and in the organ donation process are discussed, as well as potential strategies to optimize the partial pressure of oxygen to perform the apnea test according to the current recommendations.

Relatamos o caso de um paciente que evoluiu com suspeita de morte encefálica associada à atelectasia e à hipoxemia moderada a grave, apesar de instituídos ventilação protetora, sistema de aspiração traqueal fechado, pressão positiva ao final da expiração moderada e manobra de recrutamento. Diante da não obtenção de pressão parcial de oxigênio adequada para o teste de apneia, optamos por pronar o paciente, utilizar pressão positiva expiratória final mais elevada, realizar nova manobra de recrutamento e ventilar com volume corrente mais elevado (8mL/kg), sem ultrapassar pressão de platô de 30cmH2O. O teste de apneia foi realizado em posição prona, com válvula de pressão positiva contínua nas vias aéreas acoplada em tubo T. O atraso no diagnóstico foi de 10 horas; a doação de órgãos não foi possível devido à parada circulatória. Este relato demonstra as dificuldades para obtenção de níveis de pressão parcial de oxigênio mais altos para a realização do teste de apneia. Os atrasos que isso pode acarretar ao diagnóstico de morte encefálica e ao processo de doação de órgãos são discutidos, além de potenciais estratégias de otimização da pressão parcial de oxigênio para realização do teste, conforme as recomendações atuais.

PubMed Disclaimer

Conflict of interest statement

Conflicts of interest: None.

Figures

Figure 1
Figure 1
Head CT scans before and after decompressive craniectomy (sections at the level of the septum pellucidum). (A) Computed tomography of the skull with 18 hours of evolution. (B) Postoperative computed tomography scan (36 hours of evolution) revealed good surgical results. (C) Computed tomography of the skull with 60 hours of evolution and a moderate midline deviation. (D) Computed tomography of the skull with 96 hours of evolution and a significant midline deviation.
Figure 2
Figure 2
Anteroposterior chest X-ray obtained while the patient was in bed.
See this image and copyright information in PMC

References

    1. Wijdicks EF. Determining brain death. Continuum (Minneap Minn) 2015;21(5 Neurocritical Care):1411–1424. - PubMed
    1. Burkle CM, Sharp RR, Wijdicks EF. Why brain death is considered death and why there should be no confusion. Neurology. 2014;83(16):1464–1469. - PMC - PubMed
    1. Brasil. Conselho Federal de Medicina Resolução CFM Nº 2.173/2017. Define os critérios do diagnóstico de morte encefálica. [26/07, 2018]. https://sistemas.cfm.org.br/normas/visualizar/resolucoes/BR/2017/2173
    1. Wijdicks EF. Brain death guidelines explained. Semin Neurol. 2015;35(2):105–115. - PubMed
    1. Lévesque S, Lessard MR, Nicole PC, Langevin S, LeBlanc F, Lauzier F. Efficacy of a T-piece system and a continuous positive airway pressure system for apnea testing in the diagnosis of brain death. Crit Care Med. 2006;34(8):2213–2216. - PubMed

Publication types