New Guidelines on Pediatric Brain Death Released

News Author: Allison Gandey
CME Author: Désirée Lie, MD, MSEd

Authors and Disclosures

CME/CE Released: 09/06/2011; Valid for credit through 09/06/2012

Clinical Context

According to the study by Nakagawa and colleagues, in 1987 the guidelines for the determination of brain death in children were published by a multi-society task force. These guidelines emphasized the importance of the history and examination in determining the cause of the coma so that correctable or reversible conditions were eliminated. However, there was insufficient evidence to allow guidance for determining brain death in neonates younger than 7 days old.

This is a statement of several societies to update the 1987 guidelines for determining brain death in children. The guidelines are endorsed by the Society of Critical Care Medicine, The Section for Critical Care and Section of Neurology of the American Academy of Pediatrics, and the American College of Critical Care Medicine.

Study Synopsis and Perspective

New brain death guidelines for infants and children have been issued. Updated for the first time in nearly 25 years, the recommendations provide step-by-step instructions to help guide clinical decision making.

"These revised pediatric death diagnostic guidelines are intended to provide an updated framework in an effort to promote standardization of the neurologic examination and use of ancillary studies," reports the task force, led by Thomas Nakagawa, MD, from Wake Forest University School of Medicine in Winston-Salem, North Carolina.

A standardized checklist, provided to help ensure all components of the examination are carried out, is included as an appendix, the authors note, but they emphasize the importance of supporting families going through the loss of their child.

"Diagnosing brain death must never be rushed or take priority over the needs of the patient or the family," they conclude. "Physicians are obligated to provide support and guidance for families as they face difficult end-of-life decisions and attempt to understand what has happened to their child."

Also involved in the guidelines, published online August 28 in Pediatrics, is the Society of Critical Care Medicine, the American Academy of Pediatrics, and the Child Neurology Society. The document was also reviewed and endorsed by a number of other societies, including the American Academy of Neurology.

Because of insufficient data in the literature, recommendations for preterm infants younger than 37 weeks' gestational age are not included in these recommendations.

2 Exams

"[B]rain death in term newborns, infants and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma," the authors write.

The guidelines state that hypotension, hypothermia, and metabolic disturbances should be treated and corrected. Medications that can interfere with the neurologic examination and apnea testing should be discontinued, allowing for adequate clearance before proceeding.

The task force calls for 2 examinations, including apnea testing, separated by an observation period. They recommend that examinations be performed by different attending physicians. However, apnea testing may be performed by the same physician.

The guidelines recommend an observation period of 24 hours for term newborns to children aged 30 days. For infants and children up to age 18 years, the guidelines call for a 12-hour observation period.

The first examination determines whether the child has met the accepted neurologic examination criteria for brain death, the authors write. The second confirms brain death based on an unchanged and irreversible condition.

The task force suggests that assessment of neurologic function after cardiopulmonary resuscitation or other severe acute brain injuries be deferred for 24 hours or longer if there are concerns or inconsistencies in the examination.

Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial PaCO₂ level 20 mm Hg above the baseline and 60 mm Hg or higher, with no respiratory effort, during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed.

The guidelines state that "[a]ncillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination."

The task force says these studies may be used when components of the examination or apnea testing cannot be completed safely because of the underlying medical condition. They can also be considered if there is uncertainty about the results of the neurologic examination, if a medication effect may be present, or to reduce the interexamination observation period.

When ancillary studies are used, a second clinical examination and apnea test should be performed, and components that can be completed must remain consistent with brain death.

The complete guidelines are available online.

Last June, new brain death guidelines for adults were issued. Unlike these recommendations, the guidelines call for only 1 exam. "The original guideline did not require this either," Gary Gronseth, MD, from the University of Kansas, Kansas City, told Medscape Medical News at the time. "Some people may object, but we found that 1 exam was sufficient."

The guideline authors have disclosed no relevant financial relationships.

Pediatrics. Published online August 28, 2011. Full text

Related Link
Medscape Reference provides a thorough discussion of the impact on child death in an article entitled "Coping with the Death of a Child in the ED."

Study Highlights

• A committee consisting of representatives of various medical societies was formed and charged with providing a checklist and standardization to document brain death in children.
• The multidisciplinary committee, which consisted of physicians and nurses with expertise in pediatrics, pediatric intensive care and critical care medicine, neurology, neurosurgery, and neuroradiology, formed 3 working groups, each charged with reviewing the literature in 3 areas.
• The 3 areas were examination criteria and observation periods; ancillary testing; and declaration of death by medical personnel, including legal and ethical implications.
• A strong recommendation was made if greater than 80% of the committee voted yes, a weak recommendation when less than 80% and more than 20% voted yes, and no recommendation was made if less than 60% of the committee voted yes on a criterion.
• The committee recognized that no national death law existed and that physicians should be familiar with local and state laws and policies.
• The committee also noted that, in some states, the age of the pediatric trauma patient was defined as younger than 14 years old.
• Determination of brain death in newborns, infants, children, and adolescents is based on a clinical diagnosis with absence of neurologic function and a known irreversible cause of coma.
• Recommendations for infants of younger than 37 weeks' gestation are not included in this guideline because of lack of evidence and data.
• 2 examinations, including apnea testing with each examination separated by an observation period, are required.
• The observation period should be no less than 24 hours for term newborns (≥ 37 weeks' gestational age) to age 30 days, and 12 hours for infants and children (ages 30 days to 18 years).
• The 2 examinations should be performed by different attending physicians.
• Qualified clinicians for the examination include pediatric intensivists and neonatologists, pediatric neurologists and neurosurgeons, pediatric trauma surgeons, and pediatric anesthesiologists with critical care training.
• Adult specialists should have special training for children 0 to 18 years old.
• Apnea testing may be performed by the same physician.
• The first examination determines that the child has met the required neurologic criteria for brain death.
• The second examination confirms that the brain death is the result of an irreversible and unchanged condition.
• Assessments after cardiopulmonary resuscitation or other acute brain injuries should be deferred for at least 24 hours or longer if there are concerns or inconsistencies in the examination.
• Apnea testing to support a diagnosis of brain death must be performed safely and requires documentation of arterial PaCO₂ of 20 mm Hg above the baseline and 60 mm Hg and above with no respiratory effort during the testing period.
• If oxygen saturation falls below 85%, hemodynamic stability limits completion of apnea testing, and the child should be placed back on ventilatory support to restore oxygen saturation.
• Another attempt may be made at apnea testing or an ancillary study used to determine brain death.
• If apnea testing cannot be safely completed, an ancillary test should be performed.
• Ancillary studies are not required to establish brain death and should not be used as substitutes for a neurologic examination.
• Ancillary studies are indicated (1) if examination or apnea testing cannot be completed because of the patient's condition; (2) if there is uncertainty about the neurologic examination; (3) if a medication effect may be present; or (4) if the inter-examination observation period needs to be reduced.
• A 4-vessel cerebral angiography is the gold standard for determining absence of cerebral blood flow and must be performed to standards of the American College of Radiology and the Society of Nuclear Medicine.
• Use of electroencephalogram to establish electrocerebral silence and use of radionuclide testing remain the most widely used tests for brain death.
• Electroencephalographic testing must be to the standard of the American Electroencephalographic Society.
• A waiting period of 24 hours is recommended for radionuclide studies for a subsequent study.
• If an ancillary study supports the first neurologic examination diagnosis of brain death, the interobservation interval may be reduced and the second examination and apnea testing performed at any time thereafter for children of all ages.

Clinical Implications

• Determination of brain death in newborns and children requires 2 examinations 24 hours apart, and 2 apnea tests performed by trained specialists.
• Ancillary tests for brain death in newborns and children are used only if the examination or apnea testing cannot be completed, if there is ambiguity about the neurologic examination or a medication effect, or if the interobservation period needs to be reduced.