Declaring Brain Death in Infants
and Children
Bert E. Johansson, MD,PhD,FAAP
Brain Death and Organ Donation
Definitions of Death:
• Cardiorespiratory death: irreversible cessation of
circulatory and respiratory function
• Whole brain death: irreversible cessation of all
functions of the entire brain
• Partial brain death (controversial): irreversible
cessation of brain functions necessary for personhood
Alternative views of death
“Higher brain” or partial brain concepts of death focus
on:
– loss of cognitive functions
– loss of capacity for memory, reasoning, and other higher brain
functions
– loss of personal identity
While many individuals feel that loss of the above
capacities make a person “as good as dead,” These
views are not universally held and currently cannot be
measured.
At present we are left with defining death in the PICU
by measurable parameters.
Uniform Determination of Death Act
1982
The Uniform Determination of Death Act forms the
legal basis for the recognition of brain death in the
US. This act states that an individual is dead after:
• Irreversible cessation of circulatory and respiratory
functions, or
• Irreversible cessation of all functions of the entire brain,
including the brain stem.
Determination of death must be made in accordance
with accepted medical standards.
Complicating factors in defining
and explaining death
– Confusing use of terminology when speaking with families,
e.g. “continuing life support” in the face of brain death
while awaiting organ donation
– Clinical findings may not support irreversible loss of all
brain functions, e.g. lack of diabetes insipidus when all other
findings are consistent with brain death
• Different and evolving religious definitions of death
Orthodox Jewish tradition
Islamic tradition
Fundamentalist Christian
Diagnosis Of Death By Neurologic
Criteria
Locally used guidelines are adapted from
the President’s Commission, 1981, and the
Task Force for the Determination of Brain
Death in Children (AAP), 2011:
Comparison of 1987 and 2011 Guidelines
2011 Guidelines on Brain Death
Determination of brain death in neonates, infants
and children relies on a clinical diagnosis
• Based on the absence of neurologic function with
a known irreversible cause of coma.
• Coma and apnea must coexist to diagnose brain
death.
• Diagnosis should be made by physicians who
have evaluated the history and completed the
neurologic examinations.
2011 Guidelines on Brain Death
Exclusion of potentially reversible
causes of coma, including:
•
•
•
(severe
•
•
•
sedatives and paralyzing drugs
hypothermia
metabolic and endocrine disturbances
electrolyte or glucose disturbances)
hypotension
surgically operable intracranial conditions
other reversible causes
Clinical Testing
1.
Absence of cortical function
• Coma; no voluntary movements; no posturing; no seizures;
spinal reflexes may persist
2.
Absence of brainstem function
• No sympathetic or parasympathetic pupil regulation
•
•
•
•
•
3.
Absent oculo-cephalic and oculo-vestibular responses
Absent blink response to corneal stimulation
Absent gag response
Absent oculo-cardiac response
No breathing with standardized apnea testing
Repeated observations recommended
Plum F, Posner JB. The diagnosis of stupor and coma. 3rd ed.
Philadelphia:FA Davis, 1982:104.
2011 Guidelines on Brain Death
Prerequisites For Initiating A Brain Death
Evaluation
a. Hypotension, hypothermia, and metabolic
disturbances affect the neurological examination must
be corrected prior to examination.
b. Sedatives, analgesics, neuromuscular blockers, and
anticonvulsant agents should be discontinued for a
time based on elimination half-life of the agent.
Obtain blood or plasma levels of anticonvulsants with
sedative effects.
2011 Guidelines on Brain Death
Prerequisites For Initiating A Brain Death
Evaluation
c. The diagnosis of brain death based on neurologic
examination alone can not be made if supratherapeutic
or high therapeutic levels of sedative agents are
present. Low to mid-therapeutic levels unlikely to
affect the exam.
d. Assessment of neurologic function may be
unreliable immediately following cardiopulmonary
resuscitation or acute brain injuries and evaluation
should be deferred for 24 to 48 hours or longer.
2011 Guidelines on Brain Death
Number of examinations, examiners and
observation periods
a. Two examinations including apnea testing with each
examination separated by an observation period are
required.
a. The examinations should be performed by different
attending physicians involved in the care of the child. The
apnea test may be performed by the same physician,
preferably the attending physician who is managing
ventilator care of the child.
2011 Guidelines on Brain Death
Number of examinations, examiners and
observation periods
c. Recommended observation periods:
(1) 24 hours for neonates (37 weeks gestation to term infants 30
days of age)
(2) 12 hours for infants and children (30 days to 18 years).
d. The first examination determines the child has met neurologic
examination criteria for brain death.
The second examination, performed by a different attending
physician, confirms that the child has fulfilled criteria for brain
death.
2011 Guidelines on Brain Death
Apnea testing
a. Apnea testing must be performed safely and requires:
Documentation of an arterial PaCO2 20 mm Hg above the
baseline PaCO2 and,
> 60 mm Hg with no respiratory effort during the
testing period.
b. If the apnea test cannot be performed due to a medical
contraindication or cannot be completed because of:
• hemodynamic instability,
• desaturation to 85%, or
• an inability to reach a PaCO2 of 60 mm Hg or greater,
an ancillary study should be performed.
2011 Guidelines on Brain Death
Ancillary studies
a. Ancillary studies (EEG and radionuclide CBF)
are not required to establish brain death unless
the clinical examination or apnea test cannot
be completed
b. Ancillary studies are not a substitute for the
neurologic examination.
2011 Guidelines on Brain Death
Ancillary studies
a. For all age groups, ancillary studies can be used to assist in
making the diagnosis of brain death when
a.
Components of the examination or apnea testing cannot be
completed,
b.
if there is uncertainty about the results of the neurologic
examination; or
a.
if a medication effect may interfere with evaluation of the patient.
a.
reduce the observation period
b. When an ancillary study is used to reduce the observation
period, all aspects of the examination and apnea testing
should be completed.
2011 Guidelines on Brain Death
Ancillary studies
d. When an ancillary study is used because there are inherent
examination limitations, then components of the examination
done initially should be completed.
e. If the ancillary study is equivocal, the patient cannot be
pronounced dead.
• The patient should continue to be observed until brain death can be
declared on clinical examination criteria and apnea testing, or a
follow-up ancillary study can be performed.
• A waiting period of 24 hours is recommended before further cinical
reevaluation or repeat ancillary study is performed.
• Supportive patient care should continue during this time period.
Confirmatory testing
In the US, confirmatory tests are not required under
most guidelines if prerequisites are met and testing is not
confounded. Example: apnea test unlikely to be valid in
patient with cervical spine transection, necessitating
alternative testing.
Confirmatory tests do not prove brain death in the face
of clinical signs that brain death has not occurred.
Types of confirmatory testing
•
Tests of brain activity
• EEG: testing is confounded by the same issues that may
confound clinical exam (sedation,hypothermia), is plagued
by artifact in the ICU setting, and does not assess brainstem
function well
• Evoked potentials: not sufficiently validated; highly dependent
on technician and interpreters
•
Tests of blood flow
• 4-vessel contrast angiography
• radionuclide scintigraphy: less invasive;
• transcranial Doppler sonography: reliable in experienced hands
only
EEG Recording Exhibiting Electrocerebral Silence
Moshe SL, et al, Pediatric Brain Death and Organ/Tissue Retrieval,
Kaufman HH ed., 1989 Plenum Publishing Co, New York, p.144
Dynamic Radionuclide Cerebral
Angiogram Consistent with Brain Death
Goodman J, et al, Pediatric Brain Death and Organ/Tissue Retrieval,
Kaufman HH ed., 1989 Plenum Publishing Co, New York, p.144
Abnormal static phase radionuclide cerebral imaging scan, in
which no radionuclide material is detected within the cranial vault.
The central “hot spot” reflects circulation to the patient’s nose,
which serves to confirm the entrance of radionuclide up to the level
of the common carotid artery.
Schwartz JA, et al, Pediatric Brain Death and Organ/Tissue Retrieval,
Kaufman HH ed., 1989 Plenum Publishing Co, New York, p.144
2011 Guidelines on Brain Death
Declaration of Death
a. Death is declared after confirmation and completion
of the second clinical examination and apnea test.
b. When ancillary studies are used, documentation of
components from the second clinical examination that
can be completed must remain consistent with brain
death.
c. The clinical examination should be carried out by
experienced clinicians who are familiar with infants and
children, and have specific training in neurocritical care.
Discussing brain death with families
• When?
The concept should be introduced when the medical team feels that its
discussion will improve family’s understanding of the patient’s condition and
prognosis.
• Who?
A team member who has a good rapport with the family, has a full
understanding that brain death is no less death than is cardiorespiratory death,
and can maintain a continuing supportive role.
• Why?
It is a generally accepted duty of medical caregivers to disclose truthful
information to families that will help them to understand their child’s
condition, and to provide guidance to them in their roles as medical decision
makers.
The Family Who Refuses The
Diagnosis Of Brain Death
• Families may be unable to understand or to accept
the diagnosis of brain death
• Contributing factors
• Lack of trust
• Mixed messages
• Sudden nature of many events leading to
brain
death
Approach To The Reluctant
Family
• Patience; consistent messages given in a
compassionate manner
• Consider involving clergy or others in whom
the family has confidence
• Consider and respect religious beliefs; some
states allow religious beliefs to override
local hospital policy