The Authors Reply: Regarding Omitting Apnea Testing in a Patient on Vasopressors

  
NCJ_cover.jpgBy Julius Gene S. Latorre, Elena B. Schmidt & David M. Greer

First Online: 20 April 2020

This comment refers to the article available at https://doi.org/10.1007/s12028-020-00966-8 and https://doi.org/10.1007/s12028-020-00934-2.

We thank Dr. Bloria for his thoughtful and important comment regarding our manuscript and our decision not to perform the apnea test in our patient. We agree strongly that apnea test is an integral part in the clinical determination of brain death. However, apnea test in selected patients may not be safe due to potential development or worsening of hemodynamic instability, arrhythmia, or cardiac arrest, potentially compromising the potential for organ donation in eligible patients. It is true that the patient in our report fulfilled all the prerequisites for apnea testing and brain death evaluation which includes having a systolic blood pressure above or equal to 100 mmHg. This blood pressure was, however, achieved despite the patient’s compromised hemodynamic status using high doses of multiple vasopressors. Although most patients being evaluated for brain death are able to tolerate apnea testing without significant complications, it is not uncommon for bedside clinicians to not attempt apnea testing due to hemodynamic instability. In a series of 147 patients cited by Dr Bloria, apnea test was not attempted in 13 due to severe hemodynamic instability and two were aborted before completion due to hypotension or hypoxia [1]. In a review of 608 patients, 124 hemodynamic complications were noted including 111 patients developing significant hypotension, nine developing arrhythmia or bradycardia, and four developing cardiac arrest [2]. In another series of 145 patients, cardiovascular complications were seen during apnea test in 26% of cases, most commonly hypotension, and the most common predisposing factor includes pre-apnea test hypotension or use of inotropics [3].

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