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Prerequisites (all must be checked)
▫ Coma, irreversible and cause known
▫ Neuroimaging explains coma
▫ CNS depressant drug effect absent (if indicated toxicology screen;
if barbiturates given, serum level 10 g/mL)
▫ No evidence of residual paralytics (electrical stimulation if paralytics used).
▫ Absence of severe acid-base, electrolyte, endocrine abnormality
▫ Normothermia or mild hypothermia (core temperature 36°C)
▫ Systolic blood pressure 100 mm Hg
▫ No spontaneous respirations
Examination (all must be checked)
▫ Pupils nonreactive to bright light
▫ Corneal reflex absent
▫ Oculocephalic reflex absent (tested only if C-spine integrity
ensured)
▫ Oculovestibular reflex absent
▫ No facial movement to noxious stimuli at supraorbital nerve, temporomandibular joint
▫ Gag reflex absent
▫ Cough reflex absent to tracheal suctioning
▫ Absence of motor response to noxious stimuli in all 4 limbs (spinally mediated reflexes are permissible)
Apnea testing (all must be checked)
▫ Patient is hemodynamically stable
▫ Ventilator adjusted to provide normocarbia (PaCo2 34 – 45 mm Hg)
▫ Patient preoxygenated with 100% FiO2 for 10 minutes to
PaO2 200 mm Hg
▫ Patient well-oxygenated with a PEEP of 5 cm of water
▫ Provide oxygen via a suction catheter to the level of the carina at 6
L/min or attach T-piece with CPAP at 10 cm H2O
▫ Disconnect ventilator
▫ Spontaneous respirations absent
▫ Arterial blood gas drawn at 8 –10 minutes, patient reconnected to
ventilator
▫ PCO2 60 mm Hg, or 20 mm Hg rise from normal baseline value
OR:
▫ Apnea test aborted
Ancillary testing (only 1 needs to be performed; to be ordered only if
clinical examination cannot be fully performed due to patient factors,
or if apnea testing inconclusive or aborted)
▫ Cerebral angiogram
▫ HMPAO SPECT
▫ EEG
▫ TCD
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