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Variability in brain death determination practices in children
1Department of Critical Care Medicine, Children's National Medical Center, Washington, DC 20010, USA.
Insights
Practices for determining brain death in pediatric intensive care units (PICUs) show significant variability, impacting organ procurement. Adherence to guidelines and improved medical examiner cooperation are needed for better outcomes.
Area of Science:
- Pediatric critical care medicine
- Neurology
- Organ donation and transplantation
Background:
- Determining brain death in children is complex.
- Variability in diagnostic practices can affect patient care and organ procurement.
- Existing guidelines aim to standardize brain death determination.
Purpose of the Study:
- To investigate variability in brain death determination practices.
- To assess organ procurement outcomes in pediatric intensive care units (PICUs).
Main Methods:
- Prospective cohort study in pediatric intensive care units.
- Included children undergoing brain death evaluations.
- Collected data on diagnostic tests, organ procurement, and reasons for nonprocurement.
Main Results:
- 37% of deaths were classified as brain deaths.
- Significant variability observed in apnea testing and confirmatory tests.
- Solid organ procurement was successful in 32% of cases.
- Common reasons for nonprocurement included parental refusal and medical examiner involvement.
Conclusions:
- Substantial variability exists in pediatric brain death determination criteria.
- Some practices contradict established guidelines for apnea testing.
- Improved medical examiner cooperation could enhance organ procurement rates.
Objective:
To investigate variability in practices for determining brain death and organ procurement results in pediatric intensive care units (PICUs).
Design:
Prospective cohort study.
Setting:
Pediatric ICUs.
Patients:
Children undergoing brain death evaluations selected from 5415 consecutive PICU admissions.
Main Outcome Measures:
Data from children undergoing brain death evaluations including number of coma examinations, number and duration of apnea tests, PCO2 measurements at the end of the apnea test, ancillary tests used to confirm brain death, organ procurement, and reasons for nonprocurement.
Results:
A total of 93 (37%) of 248 deaths were brain deaths. Compared with the other deaths, children who were classified as brain dead were sicker on admission (mean Pediatric Risk of Mortality [PRISM] score +/- SD: 31 +/- 11 vs 23 +/- 12, P < .001; pre-ICU cardiopulmonary resuscitation: 72% vs 40%, P < .001), and had more traumatic injuries (42% vs 12%, P < .001). Variability in apnea testing included lack of apnea testing in 23 patients (25%) and controversial apnea testing practices in 20 patients (22%). Three patients (3%) had brain death evaluations within hours of discontinuing barbiturate infusions, and four of 30 patients younger than 1 year did not have a confirmatory test. Solid organ procurement was successful in 32%. Reasons for nonprocurement included parental refusal (12%), disease state (12%), and medical examiner's case (22%).
Conclusions:
Substantial variability exists in the criteria used by clinicians for the diagnosis of brain death. Some practices are contradictory to the Guidelines for the Determination of Brain Death in Children and to recommendations for apnea testing. Organ procurement could be improved by increased medical examiner cooperation.
