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Bolt B, Muakkassa F, Bruening L, Marcus C, Cunningham B, Pawlak E, Gandee R, Newey C. Cardiac Oscillations Complicating Brain Death Diagnosis. Case Rep Crit Care 2023; 2023:1132406. [PMID: 37727825 PMCID: PMC10506872 DOI: 10.1155/2023/1132406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 02/24/2023] [Accepted: 07/15/2023] [Indexed: 09/21/2023] Open
Abstract
Death by neurologic criteria (DNC) or brain death is a clinical diagnosis. It is often complicated by variations in policies as well as confounders on examination. We discuss here the case of a 27-year-old male who had a cardiac arrest following toxic gaseous exposure. He ultimately progressed to brain death but was identified as having cardiac oscillations during clinical assessments that complicated the diagnosis. We discuss the case as well as the maneuvers used to clarify that the "triggered breaths" on the ventilator were indeed cardiac oscillations.
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Affiliation(s)
- Brittany Bolt
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Farid Muakkassa
- Section of Trauma, Cleveland Clinic Akron General Hospital, Akron, Ohio, USA
| | - Lindsay Bruening
- Section of Neurology, Cleveland Clinic Akron General Hospital, Akron, Ohio, USA
| | - Cameron Marcus
- Section of Emergency Medicine, Cleveland Clinic Akron General Hospital, Akron, Ohio, USA
| | - Brittany Cunningham
- Section of Pharmacy, Cleveland Clinic Akron General Hospital, Akron, Ohio, USA
| | - Erin Pawlak
- Section of Neurology, Cleveland Clinic Akron General Hospital, Akron, Ohio, USA
| | - Richard Gandee
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Section of Neurology, Cleveland Clinic Akron General Hospital, Akron, Ohio, USA
| | - Christopher Newey
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurocritical Care and ICU-EEG, Sanford Health, Sioux Falls, OH, USA
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Spears W, Mian A, Greer D. Brain death: a clinical overview. J Intensive Care 2022; 10:16. [PMID: 35292111 PMCID: PMC8925092 DOI: 10.1186/s40560-022-00609-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/06/2022] [Indexed: 01/01/2023] Open
Abstract
Brain death, also commonly referred to as death by neurologic criteria, has been considered a legal definition of death for decades. Its determination involves many considerations and subtleties. In this review, we discuss the philosophy and history of brain death, its clinical determination, and special considerations. We discuss performance of the main clinical components of the brain death exam: assessment of coma, cranial nerves, motor testing, and apnea testing. We also discuss common ancillary tests, including advantages and pitfalls. Special discussion is given to extracorporeal membrane oxygenation, target temperature management, and determination of brain death in pediatric populations. Lastly, we discuss existing controversies and future directions in the field.
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Affiliation(s)
- William Spears
- Department of Neurology, Boston University, Boston Medical Center, 85 East Concord Street, Room 1145, Boston, MA, 02118, USA
| | - Asim Mian
- Department of Radiology, Boston University, Boston Medical Center, 820 Harrison Avenue FGH, 3rd floor, Boston, USA
| | - David Greer
- Department of Neurology, Boston University, Boston Medical Center, 85 East Concord Street, Room 1145, Boston, MA, 02118, USA.
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Shewmon DA. Statement in Support of Revising the Uniform Determination of Death Act and in Opposition to a Proposed Revision. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2021; 48:jhab014. [PMID: 33987668 DOI: 10.1093/jmp/jhab014] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Discrepancies between the Uniform Determination of Death Act (UDDA) and the adult and pediatric diagnostic guidelines for brain death (BD) (the "Guidelines") have motivated proposals to revise the UDDA. A revision proposed by Lewis, Bonnie and Pope (the RUDDA), has received particular attention, the three novelties of which would be: (1) to specify the Guidelines as the legally recognized "medical standard," (2) to exclude hypothalamic function from the category of "brain function," and (3) to authorize physicians to conduct an apnea test without consent and even over a proxy's objection. One hundred seven experts in medicine, bioethics, philosophy, and law, spanning a wide variety of perspectives, have come together in agreement that while the UDDA needs revision, the RUDDA is not the way to do it. Specifically, (1) the Guidelines have a non-negligible risk of false-positive error, (2) hypothalamic function is more relevant to the organism as a whole than any brainstem reflex, and (3) the apnea test carries a risk of precipitating BD in a non-BD patient, provides no benefit to the patient, does not reliably accomplish its intended purpose, and is not even absolutely necessary for diagnosing BD according to the internal logic of the Guidelines; it should at the very least require informed consent, as do many procedures that are much more beneficial and less risky. Finally, objections to a neurologic criterion of death are not based only on religious belief or ignorance. People have a right to not have a concept of death that experts vigorously debate imposed upon them against their judgment and conscience; any revision of the UDDA should therefore contain an opt-out clause for those who accept only a circulatory-respiratory criterion.
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Affiliation(s)
- D Alan Shewmon
- University of California Los Angeles, Los Angeles, California, USA
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Apparent ventilator triggering in a brainstem dead patient. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Mu S, Rautela L, Howard ME, Hannan L. Autocycling During Noninvasive Positive Pressure Ventilation Producing a Prolonged Severe Apnea and Syncope. J Clin Sleep Med 2019; 15:663-665. [PMID: 30952221 DOI: 10.5664/jcsm.7738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 01/09/2019] [Indexed: 11/13/2022]
Abstract
ABSTRACT Autocycling is a form of patient-ventilator asynchrony that can occur during mechanical ventilation. In the case described, autocycling during noninvasive ventilation led to severe hyperventilation and subsequently produced a prolonged central apnea that resulted in syncope. This case represents the first description of a severe adverse event from autocycling during noninvasive ventilation.
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Affiliation(s)
- Susana Mu
- Austin Health, Heidelberg, Victoria, Australia.,Northern Health, Epping, Victoria, Australia
| | - Linda Rautela
- Austin Health, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Victorian Respiratory Support Service, Heidelberg, Victoria, Australia
| | - Mark E Howard
- Austin Health, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Victorian Respiratory Support Service, Heidelberg, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Liam Hannan
- Austin Health, Heidelberg, Victoria, Australia.,Northern Health, Epping, Victoria, Australia.,Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Victorian Respiratory Support Service, Heidelberg, Victoria, Australia
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Robba C, Iaquaniello C, Citerio G. Death by neurologic criteria: pathophysiology, definition, diagnostic criteria and tests. Minerva Anestesiol 2019; 85:774-781. [PMID: 30871303 DOI: 10.23736/s0375-9393.19.13338-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Death by neurologic criteria is an irreversible sequence of events culminating in permanent cessation of cerebral functions. In this context, there are no responses arising from the brain, no cranial nerve reflexes nor motor responses to pain stimuli, and no respiratory drive. The diagnosis of death by neurologic criteria implies that there is clinical evidence of the complete and irreversible cessation of brainstem and cerebral functions. The diagnosis, confirmation, and certification of death are core skills for medical practitioners. The aim of this review is to discuss the pathophysiology and definition of death by neurological criteria, describing the clinical assessment, and the use of ancillary tests for the diagnosis of brainstem death.
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Affiliation(s)
- Chiara Robba
- Department of Anesthesia and Intensive Care, IRRCS for Oncology, University of Genoa, Genoa, Italy
| | - Carolina Iaquaniello
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Monza-Brianza, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Monza-Brianza, Italy - .,Unit of Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza-Brianza, Italy
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Bulleri E, Fusi C, Bambi S, Pisani L. Patient-ventilator asynchronies: types, outcomes and nursing detection skills. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:6-18. [PMID: 30539927 PMCID: PMC6502136 DOI: 10.23750/abm.v89i7-s.7737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/05/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Mechanical ventilation is often employed as partial ventilatory support where both the patient and the ventilator work together. The ventilator settings should be adjusted to maintain a harmonious patient-ventilator interaction. However, this balance is often altered by many factors able to generate a patient ventilator asynchrony (PVA). The aims of this review were: to identify PVAs, their typologies and classifications; to describe how and to what extent their occurrence can affect the patients' outcomes; to investigate the levels of nursing skill in detecting PVAs. METHODS Literature review performed on Cochrane Library, Medline and CINAHL databases. RESULTS 1610 records were identified; 43 records were included after double blind screening. PVAs have been classified with respect to the phase of the respiratory cycle or based on the circumstance of occurrence. There is agreement on the existence of 7 types of PVAs: ineffective effort, double trigger, premature cycling, delayed cycling, reverse triggering, flow starvation and auto-cycling. PVAs can be identified through the ventilator graphics monitoring of pressure and flow waveforms. The influence on patient outcomes varies greatly among studies but PVAs are mostly associated with poorer outcomes. Adequately trained nurses can learn and retain how to correctly detect PVAs. CONCLUSIONS Since its challenging interpretation and the potential advantages of its implementation, ventilator graphics monitoring can be classified as an advanced competence for ICU nurses. The knowledge and skills to adequately manage PVAs should be provided by specific post-graduate university courses.
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Henry NR, Russian CJ, Nespral J. Identifying Potential Ventilator Auto-Triggering Among Organ Procurement Organization Referrals. Prog Transplant 2016; 26:129-34. [DOI: 10.1177/1526924816640649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Context: Ventilator auto-trigger is the delivery of an assisted mechanical ventilated breath over the set ventilator frequency in the absence of a spontaneous inspiratory effort and can be caused by inappropriate ventilator trigger sensitivity. Ventilator auto-trigger can be misinterpreted as a spontaneous breath and has the potential to delay or prevent brain death testing and confuse health-care professionals and/or patient families. Objective: To determine the frequency of organ donor referrals from 1 Organ Procurement Organization (OPO) that could benefit from an algorithm designed to assist organ recovery coordinators to identify and correct ventilator auto-triggering. Design: This retrospective analysis evaluated documentation of organ donor referrals from 1 OPO in central Texas during the 2013 calendar year that resulted in the withdrawal of care by the patient’s family and the recovery of organs. Main Outcome Measures: The frequency of referrals that presented with absent brain stem reflexes except for additional respirations over the set ventilator rate was determined to assess for the need of the proposed algorithm. Results: Documentation of 672 organ procurement organization referrals was evaluated. Documentation from 42 referrals that resulted in the withdrawal of care and 21 referrals that resulted in the recovery of organs were identified with absent brain stem reflexes except for spontaneous respirations on the mechanical ventilator. As a result, an algorithm designed to identify and correct ventilator auto-trigger could have been used 63 times during the 2013 calendar year.
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Affiliation(s)
- Nicholas R. Henry
- Department of Respiratory Care, Texas State University, San Marcos, TX, USA
| | | | - Joseph Nespral
- Clinical Services, Texas Organ Sharing Alliance, San Antonio, TX, USA
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Ding ZY, Zhang Q, Wu JW, Yang ZH, Zhao XQ. Apparently Recovering Breath Function in Brain Death. Chin Med J (Engl) 2015; 128:2969-71. [PMID: 26521800 PMCID: PMC4756877 DOI: 10.4103/0366-6999.168079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
| | | | | | | | - Xing-Quan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
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Noujeim C, Bouakl I, El-Khatib M, Bou-Khalil P. Ventilator auto-cycling from cardiogenic oscillations: case report and review of literature. Nurs Crit Care 2013; 18:222-8. [PMID: 23968440 DOI: 10.1111/nicc.12029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 04/21/2013] [Accepted: 04/22/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Brain death is the total loss of all brain and brain stem functions, and its diagnosis is often confirmed by an apnoea test, which relies on disconnecting the patient from the ventilator. Auto-triggering or auto-cycling is defined as a ventilator being triggered in the absence of patient effort, intrinsic respiratory drive or inspiratory muscle activity. Ventilator auto-triggering could delay the diagnosis of brain death leading to unnecessary admission for the patient and false hopes of recovery for the family. METHODS We report a case of ventilator auto-triggering associated with cardiogenic oscillations in a female patient. RESULTS We confirmed the finding of ventilator auto-triggering by changing the patient's position and reassessing the triggering thresholds. Brain death was then confirmed by apnoea test. CONCLUSION This case is presented to arouse the awareness of the medical staff and nurses to this phenomenon, which can mimic an intrinsic respiratory effort in patients allegedly diagnosed with brain death. Along with this case report, we review the English language publications for similar cases.
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Affiliation(s)
- Carlos Noujeim
- Division of Pulmonary and Critical Care, Department of Medicine, Tannourine Governmental Hospital, Batroun, Lebanon
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