Non-barbiturate, drug-induced reversible loss of brainstem reflexes

Criteria for establishing brain death require the clinician to rule out reversible causes for loss of brainstem function. Aside from barbiturates, few medications are known to abolish brainstem reflexes entirely. Case report. A 60-year-old woman underwent a five-vessel coronary artery bypass graft after receiving streptokinase and heparin for an acute myocardial infarction. Postoperatively, she was alert, following commands, and moving all extremities. Early on postoperative day 2, she developed pulseless ventricular fibrillation requiring cardiopulmonary resuscitation and defibrillation. She received a lidocaine bolus (100 mg) followed by lidocaine drip (2 mg/min). She was alert following this episode. Nine hours later, she experienced ventricular tachycardia requiring cardioversion. She was bolused with lidocaine (75 mg), her lidocaine drip was increased (4 mg/min), and amiodarone and bretylium drips were started. She was alert and following commands after this episode. Later on postoperative day 2, she lost her distal pulses. She was believed to have embolized from her aorta and was placed on heparin. Heparin was then discontinued due to presumptive heparin-induced thrombocytopenia and thrombosis syndrome (HITTS). During the afternoon of postoperative day 2, she …