Ventilator autotriggering An underestimated phenomenon in the determination of brain death The verification of apnea plays a key role in the clinical declaration of brain death but ventilator autotriggering can mimic an intrinsic respiratory drive where there is none. This phenomenon becomes relevant for the management of intensive care patients with severe cerebral injuries who have the potential of progressing to brain death and may delay or even prevent the diagnosis of brain death. It should be a consistent notable aspect in the national guidelines, especially against the background of the increasing gap between the demand and availability of donor organs.
It is widely accepted that brain death (BD) is a diagnosis based on clinical examination. However, false-positive and false-negative evaluation results may be serious limitations. Ancillary tests are used when there is uncertainty about the reliability of the neurologic examination. Computed tomography angiography (CTA) is an ancillary test that tends to have the lowest false-positive rates. However, there are various influencing factors that can have an unfavorable effect on the validity of the examination method. There are inconsistent protocols regarding the evaluation criteria such as scoring systems. Among the most widely used different scoring systems the 4-point CTA-scoring system has been accepted as the most reliable method. Appropriate timing and/or Doppler pre-testing could reduce the number of possible premature examinations and increase the sensitivity of CTA in diagnosing cerebral circulatory arrest (CCA). In some cases of inconclusive CTA, the whole brain computed tomography perfusion (CTP) could be a crucial adjunct. Due to the increasing significance of CTA/CTP in determining BD, the methodology (including benefits and limitations) should also be conveyed via innovative electronic training tools, such as the BRAINDEXweb teaching tool based on an expert system.
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