(128) Managing Brain Death Confounders, Physiology, and Family Dynamics on Pathway to Organ Donation

Introduction: Cardiac ventilator autotriggering and complex spinal reflexes confound brain death and confuse families about prognosis. Autotriggering may be mistaken for intrinsic respiratory drive, wrongly treated with sedative/hypnotics/NMB and prolong intervals between terminal herniation and optimal organ donor care. In this case, we review autotriggering, spinal reflex brain death confounders, sensitive family communication and best timing of hormonal resuscitation.

Description: A 49-year-old male was admitted following PEA arrest. CPR/ACLS efforts and advanced airway management were initiated with ROSC. On ED arrival, seizure activity required propofol/midazolam/valproic acid and brainstem reflexes were preserved. Head CT day 1 showed anoxic-ischemic injury. By ICU Day 3, seizures were absent, CNS depressants halted and head CT showed brainstem herniation. Pupils became fixed, dilated and midpoint with absent brainstem reflexes. Hypotension dictated norepinephrine at 60 mcg/min. With brainstem herniation, T-4 and high-dose methylprednisolone stabilized blood pressure. Neurology deferred brain death testing due to patient over-breathing ventilator set rate and lower extremity movement to stimulation. Observant family questioned grim prognosis, requiring sensitive communication on normal versus current neurologic findings. Addressing respiratory rate, ventilator pressure and flow waveforms revealed oscillations matching the cardiac cycle. Flow trigger at 3 L/min was changed to pressure trigger at -2 cm H20, eliminating autotriggering. Neurology then returned for brain death testing. Family stayed at bedside during brain death testing (including apnea testing), better understanding brain death and authorizing organ donation.

Discussion: Complex spinal reflexes and autotriggering consequent to cardiac cycle may confuse families and delay brain death testing. When patients are encountered as described, ventilator graphics analysis must be done in context with neurological evaluation and ventilator trigger mode/sensitivity individualized. Cardiac instability consequent to brainstem herniation may be treated with T-4/methylprednisolone and families encouraged to remain at the bedside for sensitive communication and support during all phases of brain death testing to improve understanding and trust.