Hostname: page-component-586b7cd67f-2plfb Total loading time: 0 Render date: 2024-11-26T18:00:23.413Z Has data issue: false hasContentIssue false
  • English
  • Français

An evaluation of capnography monitoring during the apnoea test in brain-dead patients

Published online by Cambridge University Press:  01 October 2007

B. Vivien ,
J. Amour ,
A. Nicolas-Robin ,
M. Vesque ,
O. Langeron ,
P. Coriat  and
B. Riou
B. Vivien*
Affiliation:
Université Pierre et Marie Curie-Paris VI, Assistance Publique-Hôpitaux de Paris, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Department of Anesthesiology and Critical Care, Paris, France
J. Amour
Affiliation:
Université Pierre et Marie Curie-Paris VI, Assistance Publique-Hôpitaux de Paris, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Department of Anesthesiology and Critical Care, Paris, France
A. Nicolas-Robin
Affiliation:
Université Pierre et Marie Curie-Paris VI, Assistance Publique-Hôpitaux de Paris, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Department of Anesthesiology and Critical Care, Paris, France
M. Vesque
Affiliation:
Université Pierre et Marie Curie-Paris VI, Assistance Publique-Hôpitaux de Paris, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Department of Anesthesiology and Critical Care, Paris, France
O. Langeron
Affiliation:
Université Pierre et Marie Curie-Paris VI, Assistance Publique-Hôpitaux de Paris, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Department of Anesthesiology and Critical Care, Paris, France
P. Coriat
Affiliation:
Université Pierre et Marie Curie-Paris VI, Assistance Publique-Hôpitaux de Paris, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Department of Anesthesiology and Critical Care, Paris, France
B. Riou
Affiliation:
Université Pierre et Marie Curie, Assistance Publique-Hôpitaux de Paris, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Department of Emergency Medicine and Surgery, Paris, France
*
Correspondence to: Benoît Vivien, Département d’Anesthésie-Réanimation, CHU Pitié-Salpêtrière, 47-83 Boulevard de l’Hôpital, 75651 Paris Cedex 13, France. E-mail: [email protected]; Tel: +33 1 42 16 22 51; Fax: +33 1 42 16 22 69
Get access

Summary

Background and objective

Diagnosis of brain death usually requires the absence of spontaneous respiratory movements during the apnoea test and an arterial carbon dioxide partial pressure above 60 mmHg. On the other hand, although capnography (end-tidal CO2) is currently monitored in intensive care unit patients, it has not been evaluated during the apnoea test in brain-dead patients. Therefore, the aim of this prospective study was first to investigate the usefulness of capnography monitoring, and secondly to evaluate the variation of the carbon dioxide partial pressure–end-tidal CO2 gradient during the apnoea test in clinically brain-dead patients.

Methods

After local Ethics Committee approval, 60 clinically brain-dead patients were investigated. End-tidal CO2 was continuously recorded before, during and after the apnoea test. Arterial blood gases were sampled immediately before and after the apnoea test for calculation of the carbon dioxide partial pressure–end-tidal CO2 gradient.

Results

The apnoea test was clinically positive in 58 patients, whereas end-tidal CO2 was equal to 0 during the apnoea. During the 20-min apnoea test, carbon dioxide partial pressure increased from 40 ± 7 to 97 ± 19 mmHg (P < 0.001) with a rate of 2.8 ± 0.9 mmHg min−1, end-tidal CO2 increased from 31 ± 6 to 68 ± 17 mmHg (P < 0.001) and carbon dioxide partial pressure–end-tidal CO2 gradient increased from 9 ± 4 to 29 ± 10 mmHg (P < 0.001). In two patients, the apnoea test was clinically negative because of the occurrence of spontaneous respiratory movements, whereas capnography showed contemporaneously significant increases in end-tidal CO2.

Conclusions

End-tidal CO2 should be systematically monitored and recorded, at least for medico-legal considerations, during the apnoea test in brain-dead patients. The high variability in the carbon dioxide partial pressure–end-tidal CO2 gradient increase precludes any extrapolation of the carbon dioxide partial pressure from the end-tidal CO2 at the end of the apnoea test.

Keywords

BRAIN DEATHCARBON DIOXIDE, monitoring, end-tidalAPNOEA
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 24 , Issue 10 , October 2007 , pp. 868 - 875
Copyright
Copyright © European Society of Anaesthesiology 2007

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Wijdicks, EF. The diagnosis of brain death. N Engl J Med 2001; 344: 1215–1221.CrossRefGoogle ScholarPubMed
2.Wijdicks, EF. Brain death worldwide: accepted fact but no global consensus in diagnostic criteria. Neurology 2002; 58: 20–25.CrossRefGoogle ScholarPubMed
3.Willatts, SM, Drummond, G. Brainstem death and ventilator trigger settings. Anaesthesia 2000; 55: 676–677.CrossRefGoogle ScholarPubMed
4.Wijdicks, EF. Determining brain death in adults. Neurology 1995; 45: 1003–1011.CrossRefGoogle ScholarPubMed
5.Ropper, AH, Kennedy, SK, Russell, L. Apnoea testing in the diagnosis of brain death. Clinical and physiological observations. J Neurosurg 1981; 55: 942–946.CrossRefGoogle ScholarPubMed
6.Bruce, DL. Blood gas values change slowly in apneic organ donors. Anesthesiology 1986; 65: 128.CrossRefGoogle ScholarPubMed
7.Benzel, EC, Gross, CD, Hadden, TA, Kesterson, L, Landreneau, MD. The apnoea test for the determination of brain death. J Neurosurg 1989; 71: 191–194.CrossRefGoogle ScholarPubMed
8.Orliaguet, GA, Catoire, P, Liu, N, Beydon, L, Bonnet, F. Transesophageal echocardiographic assessment of left ventricular function during apnoea testing for brain death. Transplantation 1994; 58: 655–658.CrossRefGoogle ScholarPubMed
9.Paret, G, Barzilay, Z. Apnoea testing in suspected brain dead children--physiological and mathematical modelling. Intensive Care Med 1995; 21: 247–252.CrossRefGoogle ScholarPubMed
10.Goudreau, JL, Wijdicks, EF, Emery, SF. Complications during apnoea testing in the determination of brain death: predisposing factors. Neurology 2000; 55: 1045–1048.CrossRefGoogle ScholarPubMed
11.Jorgensen, PB. Clinical deterioration prior to brain death related to progressive intracranial hypertension. Acta Neurochir (Wien) 1973; 28: 29–40.CrossRefGoogle ScholarPubMed
12.Vivien, B, Haralambo, MS, Riou, B. Barotrama during apnea testing for the determination of brain death. Ann Fr Anesth Réanim 2001; 20: 370–373.CrossRefGoogle ScholarPubMed
13.Saposnik, G, Rizzo, G, Vega, A, Sabbatiello, R, Deluca, JL. Problems associated with the apnea test in the diagnosis of brain death. Neurol India 2004; 52: 342–345.Google ScholarPubMed
14.Waddell, G. Movement of critically ill patients within hospital. Br Med J 1975; 2: 417–419.CrossRefGoogle ScholarPubMed
15.Waydhas, C, Schneck, G, Duswald, KH. Deterioration of respiratory function after intra-hospital transport of critically ill surgical patients. Intensive Care Med 1995; 21: 784–789.CrossRefGoogle ScholarPubMed
16. Circulaire DGS n°96-7323 du 4 décembre 1996 relative au constat de la mort préalable au prélèvement d’organes, de tissus et de cellules à des fins thérapeutiques ou scientifiques défini par le décret n°96-1041 du 2 décembre 1996. Journal Officiel de la République Française, 4 décembre 1996 (http://www.legifrance.gouv.fr/).Google Scholar
17.Bohr, C. Ueber die Lungenathmung. Skand Arch Physiol 1891; 2: 236–268.CrossRefGoogle Scholar
18.Van Donselaar, CA, Meerwaldt, JD, van Gijn, J. Apnoea testing to confirm brain death in clinical practice. J Neurol Neurosurg Psychiatry 1986; 49: 1071–1073.CrossRefGoogle ScholarPubMed
19.Sharpe, MD, Young, GB, Harris, C. The apnea test for brain death determination: an alternative approach. Neurocrit Care 2004; 1: 363–366.CrossRefGoogle ScholarPubMed
20.Dominguez-Roldan, JM, Barrera-Chacon, JM, Murillo-Cabezas, F, Santamaria-Mifsut, JL, Rivera-Fernandez, V. Clinical factors influencing the increment of blood carbon dioxide during the apnea test for the diagnosis of brain death. Transplant Proc 1999; 31: 2599–2600.CrossRefGoogle ScholarPubMed
21.Brilli, RJ, Bigos, D. Altered apnea threshold in a child with suspected brain death. J Child Neurol 1995; 10: 245–246.CrossRefGoogle Scholar
22.Vardis, R, Pollack, MM. Increased apnea threshold in a pediatric patient with suspected brain death. Crit Care Med 1998; 26: 1917–1919.CrossRefGoogle Scholar
23.Brilli, RJ, Bigos, D. Apnea threshold and pediatric brain death. Crit Care Med 2000; 28: 1257.CrossRefGoogle ScholarPubMed
24.Hoffman, RA, Krieger, BP, Kramer, MR et al. . End-tidal carbon dioxide in critically ill patients during changes in mechanical ventilation. Am Rev Respir Dis 1989; 140: 1265–1268.CrossRefGoogle ScholarPubMed
25.Russell, GB, Graybeal, JM. Reliability of the arterial to end-tidal carbon dioxide gradient in mechanically ventilated patients with multisystem trauma. J Trauma 1994; 36: 317–322.CrossRefGoogle ScholarPubMed
26.Kerr, ME, Zempsky, J, Sereika, S, Orndoff, P, Rudy, EB. Relationship between arterial carbon dioxide and end-tidal carbon dioxide in mechanically ventilated adults with severe head trauma. Crit Care Med 1996; 24: 785–790.CrossRefGoogle ScholarPubMed
27.Seguin, P, Bleichner, JP, Branger, B, Guillou, YM, Feuillu, A, Malledant, Y. The measurement of end-tidal carbon dioxide (petCO2) is not a significant parameter to monitor in patients with severe traumatic brain injury. Can J Anaesth 2001; 48: 396–400.CrossRefGoogle Scholar
28.Kalfon, P, Rao, GS, Gallart, L, Puybasset, L, Coriat, P, Rouby, JJ. Permissive hypercapnia with and without expiratory washout in patients with severe acute respiratory distress syndrome. Anesthesiology 1997; 87: 6–17.CrossRefGoogle ScholarPubMed
29.Cybulsky, IJ, Abel, JG, Menon, AS, Salerno, TA, Lichtenstein, SV, Slutsky, AS. Contribution of cardiogenic oscillations to gas exchange in constant-flow ventilation. J Appl Physiol 1987; 63: 564–570.CrossRefGoogle ScholarPubMed
30.Mackenzie, CF, Skacel, M, Barnas, GM, Brampton, WJ, Alana, CA. Effects of cardiac oscillations and lung volume on acinar gas mixing during apnea. J Appl Physiol 1990; 68: 2013–2018.CrossRefGoogle ScholarPubMed
31.Jeret, JS, Benjamin, JL. Risk of hypotension during apnea testing. Arch Neurol 1994; 51: 595–599.CrossRefGoogle ScholarPubMed
32.Nygaard, CE, Townsend, RN, Diamond, DL. Organ donor management and organ outcome: a 6-year review from a Level I trauma center. J Trauma 1990; 30: 728–732.CrossRefGoogle ScholarPubMed
33.Melano, R, Adum, ME, Scarlatti, A, Bazzano, R, Araujo, JL. Apnea test in diagnosis of brain death: comparison of two methods and analysis of complications. Transplant Proc 2002; 34: 11–12.CrossRefGoogle ScholarPubMed
34.Bar-Joseph, G, Bar-Lavie, Y, Zonis, Z. Tension pneumothorax during apnea testing for the determination of brain death. Anesthesiology 1998; 89: 1250–1251.CrossRefGoogle ScholarPubMed
35.Vivien, B, Marmion, F, Roche, S et al. . An evaluation of transcutaneous carbon dioxide partial pressure monitoring during apnea testing in brain-dead patients. Anesthesiology 2006; 104: 701–707.CrossRefGoogle ScholarPubMed
36.Levesque, S, Lessard, MR, Nicole, PC et al. . Efficacy of a T-piece system and a continuous positive airway pressure system for apnea testing in the diagnosis of brain death. Crit Care Med 2006; 34: 2213–2216.CrossRefGoogle Scholar