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Pediatric brain death determination
Mudit Mathur1, Stephen Ashwal2
1Division of Pediatric Critical Care, Loma Linda University Children's Hospital, Loma Linda, California.
Insights
Determining brain death in children requires two clinical exams with apnea testing. Ancillary studies are supplementary, not replacements, for the neurological examination in pediatric brain death determination.
Area of Science:
- Pediatric Critical Care Medicine
- Neurology
- Forensic Medicine
Background:
- Clinical guidelines for determining brain death in children were established in 1987 and revised in 2011.
- These guidelines provide minimum standards for declaring brain death in pediatric patients.
Purpose of the Study:
- To outline the current clinical guidelines for the determination of brain death in infants and children.
- To clarify the role of ancillary studies in the process of declaring brain death.
Main Methods:
- Physiologic stability and exclusion of confounders are prerequisites.
- Two neurological examinations, including apnea testing, separated by an observation period (24 hours for neonates, 12 hours for older children).
- Apnea testing requires specific PaCO2 levels and absence of respiratory effort.
Main Results:
- Ancillary studies (EEG, cerebral blood flow) are not mandatory for brain death determination.
- Ancillary studies can be used when examinations are incomplete, uncertain, affected by medication, or to shorten observation periods.
- When ancillary studies are used, a second clinical examination and apnea test are still necessary.
Conclusions:
- The established guidelines provide a framework for determining brain death in children.
- Ancillary studies serve a supportive role and do not replace clinical neurological assessment.
- Consistency with brain death findings is required even when ancillary studies are employed.
Abstract:
Clinical guidelines for the determination of brain death in children were first published in 1987. These guidelines were revised in 2011 under the auspices of the Society of Critical Care Medicine, the American Academy of Pediatrics, and the Child Neurology Society, and provide the minimum standards that must be satisfied before brain death can be declared in infants and children. After achieving physiologic stability and exclusion of confounders, two examinations including apnea testing separated by an observation period (24 hours for term newborns up to 30 days of age, and 12 hours for infants and children from 31 days up to 18 years) are required to establish brain death. Apnea testing should demonstrate a final arterial PaCO2 20 mm Hg above the baseline and ≥ 60 mm Hg with no respiratory effort during the testing period. Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. The committee concluded that ancillary studies may be used (1) when components of the examination or apnea testing cannot be completed, (2) if uncertainty about components of the neurologic examination exists, (3) if a medication effect may be present, or (4) to reduce the interexamination observation period. When ancillary studies are used, a second clinical examination and apnea test should still be performed and components that can be completed must remain consistent with brain death.
