Case Report
Tension pneumothorax complicating apnea testing during brain death evaluation

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Abstract

Tension pneumothorax is a rare complication of the apnea test using the apneic oxygenation method. In reported cases, it has been attributed to massive air trapping beyond a supplemental oxygen cannula that was obstructing the airway. We report a case of tension pneumothorax, pneumomediastinum, and pneumoperitoneum that developed during the apnea test as a result of direct airway perforation by the supplemental oxygen cannula. We review the literature concerning catastrophic airway complications associated with the apneic oxygenation method and suggest ways to avoid them.

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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  • A new technique for avoiding barotrauma-induced complications in apnea testing for brain death

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    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

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    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.

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