Pneumothorax and pneumoperitoneum during the apnea test: how safe is this procedure?

Apnea test is a crucial requirement for determining the diagnosis of brain death (BD). There are few reports considering clinical complications during this procedure. We describe a major complication during performing the apnea test. We also analyse their practical and legal implications, and review the complications of this procedure in the literature. A 54 year-old man was admitted for impaired consciousness due to a massive intracerebral hemorrhage. Six hours later, he had no motor response, and all brainstem reflexes were negative. The patient fulfilled American Academy of Neurology (AAN) criteria for determining BD. During the apnea test, the patient developed pneumothorax, pneumoperitoneum, and finally cardiac arrest. Apnea test is a necessary requirement for the diagnosis of brain death. However, it is not innocuous and caution must be take in particular clinical situations. Complications during the apnea test could be more frequent than reported and may have practical and legal implications. Further prospective studies are necessary to evaluate the frequency and nature of complications during this practice.