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A critique of the apneic oxygenation test for the diagnosis of “brain death”*

Tibballs, James MD, MBBS

Pediatric Critical Care Medicine: July 2010 - Volume 11 - Issue 4 - p 475-478
doi: 10.1097/PCC.0b013e3181ce75dd
Feature Review Article

Objective: To determine the reliability and safety of the apneic oxygenation test to diagnose brain death for the purpose of organ donation.

Date Sources: Published scientific literature in Medline database, organ donation guidelines and neurophysiological principles described in medical textbooks.

Study Selection: Articles on brain death, apnea testing, and radionuclide scintigraphy.

Data Extraction and Synthesis: Hypercarbia with a target Paco2 of 60 mm Hg (8.0 kPa) must be reached before apnea is deemed consistent with brain death in some clinical guidelines, whereas a level of 50 mm Hg (6.7 kPa) is required in another. However, the sensitivity and specificity of the test are doubtful because some patients have commenced spontaneous respiration >60 mm Hg (8.0 kPa) and high levels of Paco2 may cause CO2 narcosis. Furthermore, the test may be harmful if the brain stem is responsive because hypercarbia may also cause intracranial hypertension and contribute to brain damage. Although guidelines for organ donation recommend the test as an essential component of brain death diagnosis, it is often not performed or performed inadequately. Wide variation in conduct of the test has prompted calls for standardization.

Conclusions: The apneic oxygenation test is unreliable in the diagnosis of brain death. It is scientifically flawed and hypothesized to cause brain death. In lieu of this test, a reliable test of brain perfusion should be mandatory, whereas the apneic oxygenation test, if performed at all, should be restricted to demonstration of apnea after brain perfusion has been shown to be absent.

From the Intensive Care Physician and Resuscitation Officer, Royal Children’s Hospital, Melbourne, Australia; and the Departments of Paediatrics and Pharmacology, The University of Melbourne, Melbourne, Australia.

The author has not disclosed any potential conflicts of interest.

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©2010The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies