Lauren Elizabeth Gorton1, Rajat Dhar2, Lindsey Woodworth3, Nitin J Anand4, Benjamin Hayes1, Joanna Isabelle Ramiro1, Abhay Kumar5. 1. Department of Neurology, St. Louis University School of Medicine, 1438 S Grand Blvd, St Louis, MO, USA. 2. Department of Neurology, Washington University in St Louis School of Medicine, St Louis, MO, USA. 3. Mid-America Transplant, St Louis, MO, USA. 4. Department of Critical Care, Missouri Baptist Medical Center, St Louis, MO, USA. 5. Department of Neurology, St. Louis University School of Medicine, 1438 S Grand Blvd, St Louis, MO, USA. abhay.kumarjha@gmail.com.
Abstract
BACKGROUND: Pneumothorax is an under-recognized complication of apnea testing performed as part of the neurological determination of death. It may result in hemodynamic instability or even cardiac arrest, compromising ability to declare brain death (BD) and viability of organs for transplantation. We report three cases of pneumothorax with apnea testing (PAT) and review the available literature of this phenomenon. METHODS: Series of three cases supplemented with a systematic review of literature (including discussion of apnea testing in major brain death guidelines). RESULTS: Two patients were diagnosed with PAT due to immediate hemodynamic compromise, while the third was diagnosed many hours after BD. An additional nine cases of PAT were found in the literature. Information regarding oxygen cannula diameter was available for nine patients (range 2.3-5.3 mm), and flow rate was available for ten patients (mean 11 L/min). Pneumothorax was treated to resolution in the majority of patients (n = 8), although only six completed apnea testing following diagnosis/treatment of pneumothorax and only three patients became organ donors afterward. Review of major BD guidelines showed that although use of low oxygen flow rate (usually ≤ 6 L/min) during apnea testing is suggested, the risk of PAT was explicitly mentioned in just one. CONCLUSION: Development of PAT may adversely affect the process of BD determination and could limit the opportunity for organ donation. Each institution should have preventive measures in place.
BACKGROUND: Pneumothorax is an under-recognized complication of apnea testing performed as part of the neurological determination of death. It may result in hemodynamic instability or even cardiac arrest, compromising ability to declare brain death (BD) and viability of organs for transplantation. We report three cases of pneumothorax with apnea testing (PAT) and review the available literature of this phenomenon. METHODS: Series of three cases supplemented with a systematic review of literature (including discussion of apnea testing in major brain death guidelines). RESULTS: Two patients were diagnosed with PAT due to immediate hemodynamic compromise, while the third was diagnosed many hours after BD. An additional nine cases of PAT were found in the literature. Information regarding oxygen cannula diameter was available for nine patients (range 2.3-5.3 mm), and flow rate was available for ten patients (mean 11 L/min). Pneumothorax was treated to resolution in the majority of patients (n = 8), although only six completed apnea testing following diagnosis/treatment of pneumothorax and only three patients became organ donors afterward. Review of major BD guidelines showed that although use of low oxygen flow rate (usually ≤ 6 L/min) during apnea testing is suggested, the risk of PAT was explicitly mentioned in just one. CONCLUSION: Development of PAT may adversely affect the process of BD determination and could limit the opportunity for organ donation. Each institution should have preventive measures in place.
Entities:
Keywords:
Apnea testing; Brain death examination; Organ donation; Pneumothorax
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