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[Determination of brain death in Intensive Pediatric Therapy]
Insights
Determining brain death in children is challenging, especially in infants. This study reports on 8 pediatric cases, highlighting diagnostic methods and the need for parental and staff emotional support.
Area of Science:
- Pediatric critical care medicine
- Neurology
- Forensic medicine
Context:
- Brain death determination in pediatric patients presents unique challenges compared to adults.
- Italian law mandates specific clinical and confirmatory tests for declaring brain death.
- Previous diagnostic protocols faced difficulties in achieving adequate hypercapnia without compromising oxygenation.
Purpose:
- To report the experience and incidence of brain death determination in infants and children.
- To evaluate the diagnostic process, including clinical criteria, confirmatory tests, and ventilator management for apnea testing.
- To discuss challenges encountered, particularly in infants, and suggest improvements for accurate and timely diagnosis.
Summary:
- Retrospective analysis of 504 pediatric intensive care unit admissions (1994-1997) identified 8 cases (1.6%) of brain death.
- Primary diagnoses included meningitis, intracerebral hemorrhage, medulloblastoma, neuroblastoma metastasis, and SIDS.
- Diagnostic challenges included achieving target PaCO2 levels and documenting cerebral circulatory arrest in infants using Doppler ultrasonography.
- Absence of cerebral blood flow persisted for days post-diagnosis, indicating potential for brain death without elevated intracranial pressure in young infants.
Impact:
- Highlights the importance of tailored ventilator strategies for apnea testing in pediatric brain death determination.
- Suggests Doppler ultrasonography through fontanelles as a viable method for assessing cerebral blood flow in infants.
- Emphasizes the critical need for psycho-emotional support for families and healthcare professionals involved in pediatric brain death assessment.
Abstract:
The subject of this paper is to report our experience in the determination of brain death in infants and children. We have retrospectively examined the incidence of brain death occurred in 504 consecutive children admitted to multidisciplinary pediatric ICU at "Bambino Gesù" Hospital of Rome during the years 1994 to 1997. According to current Italian Law, brain death was declared in 8 children (1.6%), whose primary diagnoses were: Meningitis (3 cases); nontraumatic intracerebral hemorrhage (2 cases); medulloblastoma (1 case); brain metastasis of neuroblastoma (1 case); SIDS (1 case). All brain death diagnoses were made using clinical criteria and confirmatory tests. A difficult problem was met in achieving the required Pa-CO2 values higher than 60 mmHg without unduly lowering O2 saturation. In order to obtain easily this objective we have recently switched the ventilator to intermittent mandatory volume ventilation at a rate of five stroke per minute using a FiO2 of 1 before starting the apnea test. In infants younger than one year the required cerebral circulatory arrest was documented in the pericallosal artery by doppler ultrasonography performed through the fonticuli cranii. The absence of cerebral blood flow was recorded for one to five days after clinical and electroencephalographic diagnosis of brain death, causing an unnecessary prolonged rianimative support. This also confirms that in young infants brain death may occur without a marked increase of intracranial pressure. Last, but not least, we believe that particular attention must be paid to psycho-emotional conditions of parents as well as of intensivists and nurses especially when brain death must be assessed in children.