Apnea Testing

Question 1

Apnea Testing Order

Answer 1

The apnea test has to be orders by the most responsible health practitioner (ICU attending)

The physician responsible for NDD but be presence of the test and if there is organ donation then two physicians have to be present for the entire duration of the apnea test to determine brain death

Question 2

How Many RRT should be Present for Apnea Testing

Answer 2

2 RRT and 1 RN must be present for the test

One RRT will perform the apnea test

The other RRT will run, interpret, and report the ABG

Question 3

When the Test is Run Done What Should be Done

Answer 3

When the test is being run make sure there is no confounding factors that can interfere with spontaneous respiratory efforts such as sedation, toxins, and neuromuscular blockades

If confounding factors are suspected the test should be delayed accordingly or ancillary testing should be considered

Question 4

Temperature and Apnea Testing

Answer 4

Before the test begins patient core temperature should be greater or equal to 34 degree Celsius

Question 5

Apnea Testing and Arterial Line

Answer 5

It is optimal to have an arterial line but not a requirement

Question 6

Apnea Testing and Pre Oxygenation

Answer 6

The patient must be pre-oxygenated on a FiO2 of 100% for at least 5 minutes prior to the apnea test

Question 7

If the patient is on Heat Humidity

Answer 7

If the patient is on heated humidity, bypass the humidifier and place the HME in line

Ensure the ETCO2 value is stable

Question 8

Apnea Test confirmation

Answer 8

An apnea test confirmation is defined when ALL of the following clinical criteria have been met

No spontaneous respiration observed

ABG analysis with PaCO2 greater than or equal to 60 mmHg AND greater than or equal to a 20 mmHg PaCO2 change from baseline

pH less than or equal to 7.28

Question 9

The physician should terminate the apnea test is the following is observed

Answer 9

Visible respiratory efforts

Significant hypotension refractory to vasopressor titration

MAP less then 60 mmHg AND systolic blood pressure less than 90mmHg

Desaturation with SpO2 less then 90% OR PaO2 less than 60 mmHg

Question 10

What is the very ifrst thing you should so before you start the apnea testing

Answer 10

Veriy order

Ensure all appropriate personnal is there for the procedure

Question 11

What do you check the patient for before you begin the test

Answer 11

Ensure that patient body temperate is greater than equal to 34 Celsius and hemodynamically stable

SBP greater than or equal to 90 mmHg AND MAP greater than or equal to 60 mmHg

Question 12

Before disconnecting the patient what should you dicuss with the dr

Answer 12

Prior to removing patient from the vent discuss appropriateness of performing lung recruitment maneuver with doctor

Question 13

1st ABG you Draw

Answer 13

Will preoxygenate the pt before this

Draw and analyze ABG and adjust ventilator settings to achieve PaCO2 of 35-45 AND pH 7.35-7.45

Repeat ABG until goals are met

Add the comment apnea test in the lab information system

Ensure Perform Time in lab information system is reflective of actually collection time

Question 14

What do you do after you get the first ABG stabilized

Answer 14

1. Connect manual resuscitation to O2 flowmeter and turn flow to 15L/min
   
   1. Adjust PEEP valve on resuscitator to same value as the current ventilator setting or 10 cmH2O (whichever is greater)
2. Clamp ETT on end inspiration
   
   1. This will minimize alveolar derecruitment prior to disconnection from the vent
3. Ensure the ETCO2 monitor, HMEF, flex tubing, and closed suction system is in line, disconnect the patient from the vent, and attche manual resuscitator
4. Unclamp ETT
5. Not eexact time on a single time keeping device used for entire procedure
6. Turn off ventilator or put in staby and cap ventilator circuit
7. Observe patient chest for any signs of spontaneous respirtory efforts

Question 15

How often do you draw an ABG

Answer 15

Draw, analyze, and record ABG every 5 min or more often as per the direction of the dr from the time of ventilator was disconnected

Discontinue ABG procurement when PaCO2 has risen greater than or equal to 20 mmHg above baseline AND greater than or equal to 60 mmHg AND pH is less than or equal to 7.28

Question 16

Upon Completeion of the Apnea Test

Answer 16

Upon completion of test, manually ventilate patient until ETCO2 value return to baseline

Connect the patient to the vent on appropriate settings

Discuss the appropriateness of performing a LRM post procedure with dr

Obtain ABG 30 min post apnea test

Question 17

Neurological Determination of Death Definition

Answer 17

Absence of clinical brain function when the proximal cause is known and is demonstrably irreversible

The apnea test is one component of the clinical criteria

Question 18

All the follow minimum clinical criteria for NDD must be met

Answer 18

Established etiology capable of causing neurological death with the absence of reversible condition capable of mimicking neurological death

Absent corneal responses, absent pupillary response, absent vestibulo-occular response

Deep unresponsive coma, absent brain stem reflex,absent motor response excluding spinal reflexes, absent gag and cough

Absent respiratory effort based on apnea on test

Question 19

Apnea Testing Definition

Answer 19

Component of the set of criteria in which the physician determine neurological death in a patient with a known irreversible cause of severe brain injury

Apnea testing is performed following in an assessment of other defined clinical criteria suggesting the absence of clinical brain function

Question 20

Acillary Testing

Answer 20

Diagnostic tests to be performed when the minimal clinical criteria cannot be completed or when unresolved confounding factors exists

For the purpose of NDD, the ancillary test is to demonstrate the absence of intracranial blood flow through Cerebral Radiocontrat Angiography or Radinuclide Angiography