Confounding factors in brain death: cardiogenic ventilator autotriggering and implications for organ transplantation

Brain death is characterised by a flaccid, areflexic neurological examination; fixed, dilated and midpoint pupils and total absence of intrinsic respiratory drive. A non-reversible clinical state or brain lesion must also be identified. Integral to brain death diagnosis is loss of respiratory drive. Following terminal brainstem herniation, a cardiovascular hyperdynamic state often occurs. This hyperdynamic state causes cyclical volume displacement within the chest in phase with the cardiac cycle, causing oscillations in gas flow patterns and may be reflected in ventilator airway pressure and flow waveforms. When these flow/pressure waveform oscillations meet or exceed ventilator flow or pressure trigger sensitivity, ventilator breaths may be triggered in the total absence of intrinsic respiratory drive. In a patient with no apparent neurological function who is still triggering ventilator breaths, detailed analysis of ventilator pressure/flow waveforms in context with neurological assessment findings can identify cardiac autotriggering in a brain-dead patient. Undetected, cardiogenic ventilator autotriggering results in prolonged ICU stay and potential loss of transplantable organs. Collaborative practice and aggressive surveillance to determine loss of all neurologic function and evaluate possible autotriggering in this population is paramount and can minimise ICU stay, reduce costs of care, decrease family stress and facilitate recovery of transplantable organs.