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