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Table 2 Differences in BD/DNC guidelines between adults and children

From: Brain death: a clinical overview

  Infants and children Adults
Definition States Uniform Determination of Death Act definition
Uses term “brain death”
Definition of brain death provided
States Uniform Determination of Death Act definition
Uses term “brain death”
Definition of brain death provided
Evidence-based Yes
Patients who recover function addressed
Yes
Patients who recover function addressed
Qualifications States examiner must be attending physician competent/qualified to perform brain death evaluation
Specifies a standardized checklist should be used
States that all physicians making a determination of brain death be intimately familiar with brain death criteria and have demonstrated competence in this complex examination
Specifies a standardized checklist should be used
Prerequisites Establish cause of coma
Establish that brain injury is irreversible
Therapeutic hypothermia discussed—no specific waiting period given
Consider deferring BD evaluation for 24–48 h after resuscitation
When in doubt, observe and postpone BD evaluation
Exclude mimicking conditions
Physiologic parameters normal for age
Metabolic derangements need correction
Neuromuscular blockade addressed (recommends train of four testing if recently given)
Drug intoxication (tables provided for elimination ½ life, says may need to wait several ½ lives)
Temp > 35 °C
Establish cause of coma
Establish that brain injury is irreversible
Therapeutic hypothermia discussed—no specific waiting period given
Ensure certain period of time has passed to exclude the possibility of recovery (usually several hours)
Exclude mimicking conditions
Physiologic parameters normal (SBP ≥ 100)
Metabolic derangements need correction
Neuromuscular blockade addressed (recommends train of four testing if recently given)
Drug intoxication (wait 5 ½ lives)
Temp > 36 °C
Neurologic examination Number of examinations: 2
(The first examination determines the child has met neurologic examination criteria for brain death. The second examination, confirms that the child has fulfilled criteria for brain death.)
Observation period 12 h (if age > 30 days)
Observation period 24 h (if age 37 weeks estimated gestational age to 30 days)
2 different attending evaluators
Complete neurologic exam: no mention of oculocephalic reflexes, mentions primitive reflexes for neonates/infants
Discusses spinal reflexes
Number of examination: 1
Observation period: none
Complete neurologic exam: OCR and OVR listed, mentions c-spine injury, details on OVR procedure provided
Discusses spinal reflexes
Apnea testing Mentions prerequisites
2 apnea tests required
Both tests can be done by same attending
Specifies 5–10 min of pre-oxygenation
Specifies high c-spine injury as contraindication
Recommends T-piece or self-inflating bag. Discusses problems with tracheal insufflation using catheter in ETT and problems using CPAP on ventilator
Criteria: no respiratory effort, PaCO2 ≥ 60 and ≥ 20 rise from baseline
Stop apnea test: SaO2 < 85% or hemodynamic instability (no specifics)
Mentions prerequisites, includes no prior evidence of CO2 retention
1 apnea test
Specifies 10 min of pre-oxygenation
Specifies starting PaO2 ≥ 200, drop rate to 10, PEEP to 5
Recommends tracheal insufflation using catheter in ETT
Specifies length of 8–10 min of apnea
Criteria: no respiratory effort, PaCO2 ≥ 60 or ≥ 20 rise from baseline
Stop apnea test: SaO2 < 85% for 30 s, retry with CPAP 10 or SBP < 90
Ancillary testing Acceptable reasons to use ancillary testing
When components of the examination or apnea testing cannot be completed safely due to the underlying medical condition of the patient
If there is uncertainty about the results of the neurologic examination
If a medication effect may be present
To reduce the inter-examination observation period
Ancillary studies may also be helpful for social reasons allowing family members to better comprehend the diagnosis of brain death
Acceptable tests: angiography, EEG, radionucleotide CBF
Pharmacologic agents that could affect the results of testing should be discontinued and levels determined as clinically indicated. Low to mid therapeutic levels of barbiturates should not preclude the use of EEG testing
Tables detailing EEG and CBF diagnostic yields in brain death
States if ancillary study not consistent with brain death, do not necessarily need to repeat with subsequent evaluation
Acceptable reasons to use ancillary testing
When uncertainty exists about the reliability of parts of the neurologic examination
When the apnea test cannot be performed
Acceptable tests: angiography, EEG, nuclear scan
Discussion of diagnostic yield of various tests in brain death
Death declaration Time of death not specified
Discusses addressing BD with families, effective communication, supporting families through the process, requests for ongoing organ support
Time of death: time of blood gas with appropriately elevated CO2 or time ancillary test results