Introduction: Brain death (BD) reflects death of the brainstem and is diagnosed by the presence of apnea, coma, and the lack of brainstem reflexes. Diagnosis can become challenging when clinical criteria are not entirely met, necessitating ancillary testing for confirmation. We describe an intriguing case highlighting the pitfalls of ancillary testing.
Description: A 40-year-old registered organ donor underwent a witnessed opioid overdose. On admission, the patient exhibited a GCS of 3, and a brain CT scan revealed diffuse cerebral edema. BD exam revealed absence of brain stem reflexes but minor neck and shoulder flexion on noxious stimulus testing. Apnea testing was initially deferred due to concerns of the confounding effects of methadone. A subsequent brain SPECT scan revealed findings consistent with absent cerebral and cerebellar blood flow, suggestive of BD. To our surprise, the patient then triggered spontaneous breaths while on the ventilator. Apnea testing was then performed, which revealed inspiratory-like movements. However, paCO2 increased from 42 to 95 mmHg. After shared decision-making with the family, the patient’s wishes of gifting life were honored, and the family decided to proceed with organ donation after circulatory arrest. The patient passed away 19 minutes after compassionate extubation.
Discussion: Observing spinal reflexes while performing death exam has the potential to complicate interpretation. Such movements have been documented in 13% to 79% of patients [1,2]. Moreover, the prolonged half-life of methadone, ranging from 20-35 hours, theoretically renders apnea testing less reliable due to possible suppression of the respiratory drive [3]. When apnea testing yields inadequate or inconclusive results, ancillary testing modalities might provide confirmatory results [4].
We discuss challenges faced when using ancillary testing to diagnose brain death. The patient’s methadone use led to relying on imaging to confirm the diagnosis when, in fact, ancillary testing should only be used to support the diagnosis. Given our patient had spontaneously triggered breaths, a diagnosis of brain death could not be made.
We highlight the need for standardized BD diagnosis guidelines in those who are ineligible to undergo the classical testing such as patients who are on methadone.
