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Neurocritical Care

05-04-2024 | Brain Death | Original work

A Recruitment Maneuver After Apnea Testing Improves Oxygenation and Reduces Atelectasis in Organ Donors After Brain Death

Authors: Rajat Dhar, Porche Braun, Atul Kumar, Jayesh Patel, Flavia L. Lee, Baback Arshi

Published in: Neurocritical Care

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Abstract

Background

Hypoxemia is the main modifiable factor preventing lungs from being transplanted from organ donors after brain death. One major contributor to impaired oxygenation in patients with brain injury is atelectasis. Apnea testing, an integral component of brain death declaration, promotes atelectasis and can worsen hypoxemia. In this study, we tested whether performing a recruitment maneuver (RM) after apnea testing could mitigate hypoxemia and atelectasis.

Methods

During the study period, an RM (positive end-expiratory pressure of 15 cm H2O for 15 s then 30 cm H2O for 30 s) was performed immediately after apnea testing. We measured partial pressure of oxygen, arterial (PaO2) before and after RM. The primary outcomes were oxygenation (PaO2 to fraction of inspired oxygen [FiO2] ratio) and the severity of radiographic atelectasis (proportion of lung without aeration on computed tomography scans after brain death, quantified using an image analysis algorithm) in those who became organ donors. Outcomes in RM patients were compared with control patients undergoing apnea testing without RM in the previous 2 years.

Results

Recruitment maneuver was performed in 54 patients after apnea testing, with a median immediate increase in PaO2 of 63 mm Hg (interquartile range 0–109, p = 0.07). Eighteen RM cases resulted in hypotension, but none were life-threatening. Of this cohort, 37 patients became organ donors, compared with 37 donors who had apnea testing without RM. The PaO2:FiO2 ratio was higher in the RM group (355 ± 129 vs. 288 ± 127, p = 0.03), and fewer had hypoxemia (PaO2:FiO2 ratio < 300 mm Hg, 22% vs. 57%; p = 0.04) at the start of donor management. The RM group showed less radiographic atelectasis (median 6% vs. 13%, p = 0.045). Although there was no difference in lungs transplanted (35% vs. 24%, p = 0.44), both better oxygenation and less atelectasis were associated with a higher likelihood of lungs being transplanted.

Conclusions

Recruitment maneuver after apnea testing reduces hypoxemia and atelectasis in organ donors after brain death. This effect may translate into more lungs being transplanted.
Appendix
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Literature
1.
Greer DM, Shemie SD, Lewis A, et al. Determination of brain death/death by neurologic criteria: the World Brain Death Project. JAMA. 2020;324(11):1078–97.CrossRefPubMed
2.
Wijdicks EF. In search of a safe apnea test in brain death: Is the procedure really more dangerous than we think? Arch Neurol. 1995;52(4):338–9.CrossRefPubMed
3.
Gorton LE, Dhar R, Woodworth L, et al. Pneumothorax as a complication of apnea testing for brain death. Neurocrit Care. 2016;25(2):282–7.CrossRefPubMed
4.
Yee AH, Mandrekar J, Rabinstein AA, Wijdicks EF. Predictors of apnea test failure during brain death determination. Neurocrit Care. 2010;12(3):352–5.CrossRefPubMed
5.
Copeland H, Hayanga JWA, Neyrinck A, et al. Donor heart and lung procurement: a consensus statement. J Heart Lung Transplant. 2020;39(6):501–17.CrossRefPubMed
6.
Ware LB, Landeck M, Koyama T, et al. A randomized trial of the effects of nebulized albuterol on pulmonary edema in brain-dead organ donors. Am J Transplant. 2014;14:621–8.CrossRefPubMedPubMedCentral
7.
Dhar R, Stahlschmidt E, Paramesh A, Marklin G. A randomized controlled trial of naloxone for optimization of hypoxemia in lung donors after brain death. Transplantation. 2019;103(7):1433–8.CrossRefPubMed
8.
Valapour M, Lehr CJ, Skeans MA, et al. OPTN/SRTR 2016 annual data report: lung. Am J Transplant. 2018;18(Suppl 1):363–433.CrossRefPubMed
9.
Paries M, Boccheciampe N, Raux M, et al. Benefit of a single recruitment maneuver after an apnea test for the diagnosis of brain death. Crit Care. 2012;16(4):R116.CrossRefPubMedPubMedCentral
10.
Chang SH, Kreisel D, Marklin GF, et al. Lung focused resuscitation at a specialized donor care facility improves lung procurement rates. Ann Thorac Surg. 2018;6:66.
11.
Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010;74:1911–8.CrossRefPubMed
12.
Hofmanninger J, Prayer F, Pan J, et al. Automatic lung segmentation in routine imaging is primarily a data diversity problem, not a methodology problem. Eur Radiol Exp. 2020;4(1):50.CrossRefPubMedPubMedCentral
13.
Sato Y, Nakajima S, Shiraga N, et al. Three-dimensional multi-scale line filter for segmentation and visualization of curvilinear structures in medical images. Med Image Anal. 1998;2(2):143–68.CrossRefPubMed
14.
15.
Marklin GF, O’Sullivan C, Dhar R. Ventilation in the prone position improves oxygenation and results in more lungs being transplanted from organ donors with hypoxemia and atelectasis. J Heart Lung Transplant. 2021;40(2):120–7.CrossRefPubMed
16.
Migdady I, Rae-Grant A, Greer DM. Brain death evaluation during the pandemic. Neurology. 2020;95(15):693–4.CrossRefPubMed
17.
Radaideh Y, Garg R, Abdalla AA, et al. Challenges in brain death determination and Apnea testing for patients with COVID-19. J Stroke Cerebrovasc Dis. 2020;29(12): 105419.CrossRefPubMedPubMedCentral
18.
Ahlawat A, Carandang R, Heard SO, Muehlschlegel S. The modified Apnea test during brain death determination: an alternative in patients with hypoxia. J Intensive Care Med. 2016;31(1):66–9.CrossRefPubMed
19.
Metadata
Title
A Recruitment Maneuver After Apnea Testing Improves Oxygenation and Reduces Atelectasis in Organ Donors After Brain Death
Authors
Rajat Dhar
Porche Braun
Atul Kumar
Jayesh Patel
Flavia L. Lee
Baback Arshi
Publication date
05-04-2024
Publisher
Springer US
Published in
Neurocritical Care
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI
https://doi.org/10.1007/s12028-024-01975-7