Case ReportTension pneumothorax complicating apnea testing during brain death evaluation
Section snippets
Case report
A 55-year-old woman with a past medical history notable for type 2 diabetes, pancreatitis, chronic renal insufficiency, myocardial infarction, and a cryptogenic left occipital ischemic stroke, was admitted for abdominal pain. She was found to have a small bowel infarction and underwent resection of the infarcted segment on hospital day 1. Her postoperative course was complicated by failure to wean from the ventilator. On post-operative day 4 she was noted to have decreased arousal and new left
Discussion
Apnea testing is technically challenging and has been associated with a high rate of complications. In the few studies that have examined this topic, complication rates as high as 68% have been found.4 Hypotension attributed to hypoxemia is one of the most common of these complications.2 Accordingly, methods to minimize hypoxemia have been devised. One such method, described in the American Academy of Neurology “Practice Parameters” on determining brain death in adults and known as apneic
Acknowledgement
The authors thank Dr. Allan Ropper for his thoughtful guidance and support in the preparation of this paper.
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Cited by (20)
Safety and reliability of artificial CO2 augmentation method in comparison with standard apneic oxygenation method for brain death determination
2022, Clinical Neurology and NeurosurgeryCitation Excerpt :Unfortunately, all of the commonly used apnea tests have associated complications including hypoxemia, hypotension, increased intracranial pressure, cardiac arrest, and cardiac arrhythmias which, if not controlled, might jeopardize the viability of organs for transplantation [6,7,9]. Case reports further suggest a risk of complications in the apneic oxygenation method related to placement of the cannula down the endotracheal tube including air trapping and airway trauma, which have reportedly led to pneumothorax and respiratory compromise [3,10]. Regardless of methodology, survey data suggest that standardization of practice in apnea testing suffers from a lack of physician education and familiarity with the procedure [11].
Brain death: Bilateral pneumothorax and pneumoperitoneum after an apnoea test
2019, Anaesthesia Critical Care and Pain MedicineA new technique for avoiding barotrauma-induced complications in apnea testing for brain death
2015, Journal of Clinical NeuroscienceCitation Excerpt :The authors concluded that AT is not an innocuous procedure and that complications during AT are more common than reported and serve to limit organ procurement for transplantation [11]. Burns and Russell reported a case in the Journal of Clinical Neuroscience of immediate tension pneumothorax, pneumomediastinum and pneumoperitoneum that developed during AT after a modified nasal cannula was inserted into a low lying endotracheal tube (ETT) positioned just above the carina [12]. Fatal pneumothorax and pneumoperitoneum were also described by Saposnik et al. during AT [13].
Performance of an apnea test for brain death determination in a patient receiving venoarterial extracorporeal membrane oxygenation
2014, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Furthermore, without adding supplemental high-flow oxygen, several potential complications can be avoided. For example, on rare occasions, high-flow oxygen provided through a catheter inserted into the trachea has resulted in tension pneumothorax, which could cause cardiac arrest and result in loss of organs for transplantation.9,10 Insertion of a tracheal cannula and connection to a T-piece oxygen delivery system requires handling of the endotracheal tube and setting up of a new oxygen circuit, all of which may not be required.
A critique of the apneic oxygenation test for the diagnosis of "brain death"
2010, Pediatric Critical Care MedicineCarbogen: A Safe and Effective Method for Apnea Testing to Declare Brain Death
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