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Westphal GA, Fernandes V, Westphal V, Fonseca JC, Silva LRD, Valiatti JLDS. Use of CPAP as an alternative to the apnea test during the determination of brain death in hypoxemic patients. Report of two cases. Rev Bras Ter Intensiva 2020; 32:319-325. [PMID: 32667440 PMCID: PMC7405752 DOI: 10.5935/0103-507x.20200032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 12/02/2019] [Indexed: 11/20/2022] Open
Abstract
The apnea test, which involves disconnection from the mechanical ventilator, presents risks during the determination of brain death, especially in hypoxemic patients. We describe the performance of the apnea test without disconnection from the mechanical ventilator in two patients. The first case involved an 8-year-old boy admitted with severe hypoxemia due to pneumonia. He presented with cardiorespiratory arrest, followed by unresponsive coma due to hypoxic-ischemic encephalopathy. Two clinical exams revealed the absence of brainstem reflexes, and transcranial Doppler ultrasound revealed brain circulatory arrest. Three attempts were made to perform the apnea test, which were interrupted by hypoxemia; therefore, the apnea test was performed without disconnection from the mechanical ventilator, adjusting the continuous airway pressure to 10cmH2O and the inspired fraction of oxygen to 100%. The oxygen saturation was maintained at 100% for 10 minutes. Posttest blood gas analysis results were as follows: pH, 6.90; partial pressure of oxygen, 284.0mmHg; partial pressure of carbon dioxide, 94.0mmHg; and oxygen saturation, 100%. The second case involved a 43-year-old woman admitted with subarachnoid hemorrhage (Hunt-Hess V and Fisher IV). Two clinical exams revealed unresponsive coma and absence of all brainstem reflexes. Brain scintigraphy showed no radioisotope uptake into the brain parenchyma. The first attempt at the apnea test was stopped after 5 minutes due to hypothermia (34.9°C). After rewarming, the apnea test was repeated without disconnection from the mechanical ventilator, showing maintenance of the functional residual volume with electrical bioimpedance. Posttest blood gas analysis results were as follows: pH, 7.01; partial pressure of oxygen, 232.0mmHg; partial pressure of carbon dioxide, 66.9mmHg; and oxygen saturation, 99.0%. The apnea test without disconnection from the mechanical ventilator allowed the preservation of oxygenation in both cases. The use of continuous airway pressure during the apnea test seems to be a safe alternative in order to maintain alveolar recruitment and oxygenation during brain death determination.
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Affiliation(s)
| | - Veviani Fernandes
- Centro Hospitalar Unimed, Unidade de Terapia Intensiva, Joinville, SC, Brasil
| | - Verônica Westphal
- Centro Hospitalar Unimed, Unidade de Terapia Intensiva, Joinville, SC, Brasil
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Solek-Pastuszka J, Biernawska J, Iwańczuk W, Kojder K, Chelstowski K, Bohatyrewicz R, Sawicki M. Comparison of Two Apnea Test Methods, Oxygen Insufflation and Continuous Positive Airway Pressure During Diagnosis of Brain Death: Final Report. Neurocrit Care 2020; 30:348-354. [PMID: 30209714 PMCID: PMC6420424 DOI: 10.1007/s12028-018-0608-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction Deterioration of the pulmonary function after the apnea test (AT) conducted with the classic oxygen insufflation AT (I-AT) is often observed during the brain death (BD) diagnosis procedure. In the present study, two AT methods were compared before a method is recommended for the currently revised Polish BD criteria. Methods Classic I-AT and continuous positive airway pressure AT (CPAP-AT) were performed in 60 intensive care unit patients. I-AT was performed at the end of two series of clinical tests, and approximately 1–1.5 h later, after BD was confirmed, a different method, CPAP-AT with 100% FiO2 and CPAP value of 10 cm H2O provided by a ventilator in CPAP mode was performed. The patients in I-AT and CPAP-AT groups were further divided into two subgroups: non-hypoxemic (NH) with good lung function before AT (PaO2/FiO2 index ≥ 200 mmHg) and hypoxemic (H) with poor lung function (PaO2/FiO2 index < 200 mmHg). PaO2 and PaCO2 were recorded prior to I-AT and CPAP-AT at time-point one (T1), 5 min after each test at time-point two (T2), and after 10 min prior to the end of tests at time-point three (T3). The I-AT NH subgroup consisted of 50 patients, and CPAP-AT NH subgroup 43 patients. The I-AT H subgroup consisted of 10 patients, and the CPAP-AT H subgroup 17 patients. Results In the I-AT NH subgroup, a gradual decrease in PaO2/FiO2 was observed throughout the AT but not in the CPAP-AT NH subgroup. The PaO2/FiO2 ratio during the AT in the CPAP-AT H group was stable with a slight tendency to increase but not in the I-AT H group. During the first 5 min of the AT, the mean increase in CO2 was approximately 5 mmHg/min. Most patients in all groups met the AT criteria after 5 min of the test. Conclusions The results from the study show that I-AT may compromise pulmonary function in some cases and is one of the reasons for the recommendation of a safer option, CPAP-AT, in the currently revised Polish BD criteria. During AT, the mean CO2 increase rate was 5 mmHg/min, which, in most patients, would allow the test to be completed after just 5 min.
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Affiliation(s)
- Joanna Solek-Pastuszka
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1, 71-252, Szczecin, Poland
| | - Jowita Biernawska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1, 71-252, Szczecin, Poland.
| | - Waldemar Iwańczuk
- Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Kalisz, 62-800, Kalisz, Poland
| | - Klaudyna Kojder
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1, 71-252, Szczecin, Poland
| | - Kornel Chelstowski
- Department of Laboratory Diagnostics, Pomeranian Medical University in Szczecin, Al. Powstańców Wlkp. 72j, 70-111, Szczecin, Poland
| | - Romuald Bohatyrewicz
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1, 71-252, Szczecin, Poland
| | - Marcin Sawicki
- Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1, 71-252, Szczecin, Poland
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Lie SA, Hwang NC. Challenges of Brain Death and Apnea Testing in Adult Patients on Extracorporeal Membrane Oxygenation—A Review. J Cardiothorac Vasc Anesth 2019; 33:2266-2272. [DOI: 10.1053/j.jvca.2019.01.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Indexed: 11/11/2022]
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Kramer AH, Couillard P, Bader R, Dhillon P, Kutsogiannis DJ, Doig CJ. Prevention of Hypoxemia During Apnea Testing: A Comparison of Oxygen Insufflation And Continuous Positive Airway Pressure. Neurocrit Care 2018; 27:60-67. [PMID: 28176180 DOI: 10.1007/s12028-017-0380-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSION 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.
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Affiliation(s)
| | | | - Ryan Bader
- Alberta Health Services, Calgary, Canada
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Sołek-Pastuszka J, Sawicki M, Iwańczuk W, Kojder K, Saucha W, Czajkowski Z, Chełstowski K, Bohatyrewicz R. Apnea testing using the oxygen insufflation method for diagnosis of brain death may compromise pulmonary function. J Crit Care 2017; 44:175-178. [PMID: 29128780 DOI: 10.1016/j.jcrc.2017.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/12/2017] [Accepted: 10/27/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The aim of our study was to compare the reliability and safety of the classical I-AT with the continuous positive airway pressure apnea test (CPAP-AT). MATERIAL AND METHODS In the group of 48 patients (group O), an I-AT was performed at the end of BD diagnostic procedures, and approximately 1-1.5h later CPAP-AT with 100% FiO2 and CPAP of 10cm H2O, provided by ventilator in CPAP mode. After pre‑oxygenation with 100% FiO2 for 10min, the PaO2/FiO2 ratio was recorded prior to I-AT at time-point one (T1) and prior to CPAP-AT at time-point two (T2). Group O was categorized into subgroup N-H (non-hypoxemic), consisting of 41 patients with good lung function, and subgroup H (hypoxemic) consisting of 7 patients with poor lung function. Within each subgroup PaO2/FiO2 at T1 and T2 were compared. RESULTS In Group O, PaO2/FiO2 decreased from 321±128mmHg at T1 to 291±119mmHg at T2 (p=0.004). In subgroup N-H, PaO2/FiO2 declined from 355±103 to 321±100mmHg (p=0.008), and in subgroup H, PaO2/FiO2 remained almost unchanged. Additionally, in 4 patients from subgroup N-H, PaO2/FiO2 decreased below 200mmHg at T2. CONCLUSIONS Our study indicates that I-AT may compromise pulmonary function and this may support the recommendation of safer CPAP-AT alternative.
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Affiliation(s)
- Joanna Sołek-Pastuszka
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1 Street, 71-252 Szczecin, Poland.
| | - Marcin Sawicki
- Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1 Street, 71-252 Szczecin, Poland.
| | - Waldemar Iwańczuk
- Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Kalisz, Poznańska 79 Street, 62-800 Kalisz, Poland.
| | - Klaudyna Kojder
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1 Street, 71-252 Szczecin, Poland
| | - Wojciech Saucha
- Clinical Department of Cardiac Anesthesia and Intensive Care of Silesian Center of Heart Diseases, Medical University of Silesia, M. Curie-Skłodowskiej 9 Street, 41-800 Zabrze, Poland.
| | - Zenon Czajkowski
- Department of Anaesthesiology and Intensive Therapy, Regional Hospital, Arkonska 4 Street, Szczecin, Poland.
| | - Kornel Chełstowski
- Department of Laboratory Diagnostics, Pomeranian Medical University in Szczecin, Al. Powstańców Wlkp. 72 Street, 70-111 Szczecin, Poland.
| | - Romuald Bohatyrewicz
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, Unii Lubelskiej 1 Street, 71-252 Szczecin, Poland.
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Hubbard JL, Dirks RC, Veneman WL, Davis JW. Novel method of delivery of continuous positive airway pressure for apnea testing during brain death evaluation. Trauma Surg Acute Care Open 2016; 1:e000046. [PMID: 29766073 PMCID: PMC5891697 DOI: 10.1136/tsaco-2016-000046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/22/2016] [Accepted: 11/25/2016] [Indexed: 11/03/2022] Open
Abstract
Background There are several methods for apnea testing for the evaluation of neurological death, including oxygen via T-piece, oxygen cannula inserted into the endotracheal tube, and continuous positive airway pressure (CPAP). Lung suitability for transplantation is determined in part by the partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2; P:F) ratio. We hypothesized that delivery of CPAP during apnea testing using a novel method would improve post-test P:F ratios. Methods A retrospective review was performed at a level I trauma center for all patients undergoing apnea testing from 2010 to 2016. The CPAP system used a flow-inflating bag and was made available in 2012. It was used at the discretion of the clinician. Patients were classified as having an apnea test by CPAP or by non-CPAP method (T-piece, oxygen cannula in endotracheal tube, etc). The two groups were compared for baseline characteristics and the primary outcome of postapnea test P:F ratio. Results During the study period, 145 patients underwent apnea testing; 67 patients by the CPAP method and 78 by non-CPAP method. There were no significant differences in demographics, mechanism of brain injury, pneumonia rate, smoking status, or antibiotic usage between the two groups. The pretest P:F ratio was similar between groups, but the CPAP group had significantly higher post-test P:F ratio (304 vs 250, p=0.02). There were no reported complications arising from CPAP use. Conclusions We describe a novel method of delivering CPAP by a flow-inflating bag during examination for brain death. This method led to improved oxygenation, P:F ratios, and may decrease barotrauma. The flow-inflating bag was inexpensive, easily implemented, and without adverse effects. Multicentered, prospective trials are needed to elicit significant benefit in lung donation and transplantation. Level of evidence Level IV, diagnostic tests.
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Affiliation(s)
| | - Rachel C Dirks
- Department of Surgery, UCSF Fresno, Fresno, California, USA
| | - Wade L Veneman
- Department of Respiratory Care Services, Community Regional Medical Center, Fresno, California, USA
| | - James W Davis
- Department of Surgery, UCSF Fresno, Fresno, California, USA
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Solek-Pastuszka J, Sawicki M, Iwańczuk W, Bohatyrewicz R. 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. Transplant Proc 2016; 48:2471-2472. [DOI: 10.1016/j.transproceed.2016.02.089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 02/02/2016] [Indexed: 11/27/2022]
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Wieczorek A, Gaszynski T. Boussignac CPAP system for brain death confirmation with apneic test in case of acute lung injury/adult respiratory distress syndrome - series of cases. Ther Clin Risk Manag 2015; 11:961-5. [PMID: 26124664 PMCID: PMC4476490 DOI: 10.2147/tcrm.s72279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction There are some patients with severe respiratory disturbances like adult respiratory distress syndrome (ARDS) and suspicion of brain death, for whom typical performance of the apneic test is difficult to complete because of quick desaturation and rapid deterioration without effective ventilation. To avoid failure of brain death confirmation and possible loss of organ donation another approach to apneic test is needed. We present two cases of patients with clinical symptoms of brain death, with lung pathology (acute lung injury, ARDS, lung embolism and lung infection), in whom apneic tests for recognizing brain death were difficult to perform. During typical performance of apneic test involving the use of oxygen catheter for apneic oxygenation we observed severe desaturation with growing hypotension and hemodynamic destabilization. But with the use of Boussignac CPAP system all necessary tests were successfully completed, confirming the patient’s brain death, which gave us the opportunity to perform procedures for organ donation. The main reason of apneic test difficulties was severe gas exchange disturbances secondary to ARDS. Thus lack of positive end expiratory pressure during classical performance of apneic test leads to quick desaturation and rapid hemodynamic deterioration, limiting the observation period below dedicated at least 10-minute interval. Conclusion The Boussignac CPAP system may be an effective tool for performing transparent apneic test in case of serious respiratory disturbances, especially in the form of acute lung injury or ARDS.
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Affiliation(s)
- Andrzej Wieczorek
- Department of Anesthesia and Intensive Care, Medical University of Lodz, Lodz, Poland
| | - Tomasz Gaszynski
- Department of Emergency Medicine and Disaster Medicine, Medical University of Lodz, Lodz, Poland
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