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American Journal of Critical Care. 2009;18: 496-488 doi:10.4037/ajcc2009690
Copyright © 2009 by the American Association of Critical-Care Nurses.
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Cases of Note features peer-reviewed case reports and case series that document clinically relevant findings from critical and high acuity care environments. Cases that illuminate a clinical diagnosis or a management issue in the treatment of critically and acutely ill patients and include discussion of the patient’s experience with the illness or intervention are encouraged. Proposals for future Cases of Note articles may be e-mailed to ajcc{at}aacn.org.

Cardiogenic Oscillation and Ventilator Autotriggering in Brain-Dead Patients: A Case Series

By Richard Arbour, RN, MSN, CCRN, CNRN, CCNS. Richard Arbour is a clinical nurse specialist for critical care at Albert Einstein Medical Center in Philadelphia, Pennsylvania.

Corresponding author: Richard Arbour, RN, MSN, CCRN, CNRN, CCNS, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141-3211 (e-mail address: Rich-Nrs{at}aol.com).

Brain death is manifested by a flaccid, areflexic patient on assessment of brain function with fixed and dilated pupils at midpoint, loss of consciousness, no response to stimulation, loss of brainstem reflexes, and apnea. A lesion or clinical state responsible for the loss of consciousness must be found. An integral part of clinical evaluation of brain death is apnea testing, which indicates complete loss of brainstem function and respiratory drive. Ventilator triggering or overbreathing the ventilator’s set rate may be considered consistent with intrinsic respiratory drive consequent to residual brainstem function. Ventilator autotriggering, however, may potentially occur in a brain-dead patient as a result of interaction between the hyperdynamic cardiovascular system and compliant lung tissue altering airway pressure and flow patterns. Also, chest wall and pre-cordial movements may mimic intrinsic respiratory drive. Ventilator autotriggering may delay determination of brain death, prolong the intensive care unit experience for patients and their families, increase costs, risk loss of donor organs, and confuse staff and family members. A detailed literature review and 3 cases of cardiogenic ventilator autotriggering are presented as examples of this phenomenon and highlight the value of close multidisciplinary clinical evaluation and examination of ventilator pressure and flow waveforms.


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Copyright © 2009 by the American Association of Critical-Care Nurses.