BRAIN DEATH POLICY AND PROCEDLIRES
I. Universityof North CarolinaHospitals
A. Policyor Determining
PediatricBrainDeath
Two professional
standards
must be met to certify Brain Death.l) The
physicianmustbe professionally
competent
and trainedto interpretthe ciinical
evidence
identifiedasbeingnecessary
criteriafor BrainDeath,seeSectionc. For
the LrNC PICU, those deemed appropriateare pediatric intensivists,
neurosurgeons,
and neurologists.
2) The physicianmust ha'e no conflict in
performingthis function for the patient. (potentialconflict mav exist in
professional,
economic,religious,and/orsocialarenas
) ln the situaiionwhere
organ donation may be involved, the preferredmethod will be for either
neurosurgery
andlorneurologyto performboth exams.However,the minimum
shallbe oneexamby eitherneurosurgery
or pediatricneurology
services
with the
secondexambeingperformed
by thepediatricintensivist.
B. Relationship
of BrainDeathDetermination
to Organprocuremenr
An increasing
needfor procuring
organsandtissuefromdeceased
patientsis
recognized.In general,the shorterthe time betweendeathand harvestine.the
higherthelikelihoodof successful
t'ansplantation.
Thedecisionto declare-Brain
Death must occur independentof decisionsregardingthe appropriateness
and
feasibilityof organdonation.
It is theresponsibility
ofthe attending
physician
to
discussBrain Deathwith the patient'sfamily.This communication
shouldbe
facilitated
by a healthcareprofessionals
responsible
for thepatient'swell-being
(nursing,housestaff, socialu.ork, and clergy).The approvalof the attendine
physicianis requiredto both notify carolinaDonor Services
and initiatethe
approachto patient'sfamily for donationconsent.This discussionis best
accomplished
with additionalinformationfrom third parly organprocurement
specialists.
C. Definition.
Brain death has occurredwhen cerebraland brainstemfunctionsare
irreversiblv
absent.
Absentcerebralfunctionis recognizedclinically as the lack ofreceptivityand
responsivitywith no psychological,autonomic or somatic responie to anv
externalstimulation.Absent brainstemfunction is recognizedclinically when
pupillary light, corneal, oculocephalic,oculovestibular,oropharyngeal,and
respiratoryreflexesare irreversiblyabsent.
Proceduresfor testing these reflexes are noted below. peripheral nervous
activity, including spinal cord reflexes,may persistafter brain diath; however,
decorticateand decerebrateposturingis inconsistentwith brain death.
Irreversibilityis recognized
when the causeof comais established
and is
sufficientto accountfor thelossofbrainfunction,andthepossibilityofrecovery
periodof time.
is excluded
for anappropriate
by observation
It is importantto recognize
the causeof coma,if possible,sinceabsence
of
brain functionresultingfrom headtraumahas differentimplicationsthan that
caused
by metabolicabnormality
or intoxication.
Reversible
causes
of comathat
may mimic irreversibility
includesedation,
certainintoxications,
renal,hepatic,
hypothermia,
neuromuscular
andotherelectrolyeabnormalities,
blockadeand
shock.If the causeof comacannotbe established,
thesereversibleconditions
laboratorystudies.
mustbe ruledout by appropriate
The periodof observation
will alsovary, depending
on the circumstances
and possiblecauses.In most cases,in which the causeis established
and
accounts
for coma,a periodof6 hoursis reasonable.
appropriately
The established
adult criteria1br brain deathappearvalid in infantsand
in applyingthemto premature
children,althoughcautionshouldbe exercised
prolonged
period
A
more
of observation
maybe necessary
andnewborninfants.
(Seeworksheet.)
in thispopulation.
yields
areestablished
If causeandirreversibility
andtheclinicalexamination
They may, however,
unequivocalfindings,confirmatorytestsare unnecessary.
primarilythe irreversibility
in determining
be appropriate
of braindeath,and
possiblyaccelerating
thedetermination
of thatirreversibility.
Whenappropriate,
confirmatory Iaboratory tesring may prove helpful include
radionucleotide brain
scan, transcranial
electroencephalography,
andbrainstem
evokedpotentials.
studies,
ultrasound,/Doppler
II. CLINICAI CRITEzuAFORBRAIN DEATH
in the medicalrecordin
The followingcriteriashouldbe documented
A. Prerequisites.
,.)):.:^,
auulLlult
+^
aL^
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LU UIE uallrgrt
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withtheexclusion
1. Irreversibility
ofbraininjurydemonstrated
ofreversible
conditions.
(coretemperature
over32'C).
2. Absence
of hypothermia
shockor profoundmetabolic
3. Absence
of cardiovascular
derangements,
i.e.Na < 125or K < 2.
drugs.
4. Absence
of depressant
5. Two observations
at intervalsofat least6 hoursby an intensivist,
neurologist,
or
(who
physician
licensed
neurosurgeon is a meryberofthe activestaff),or another
medicine.
applying
appropriate
practice.
to practice
standards
of medical
hasbeengraduallyshortened.
NOTE: The durationof observation
Six hoursis the
12
48
hours
may
standard,
though
to
be
requiredif
currentusual
doubtexistsabout
ofcomain adultsandchildren.
thecauseof irreversibility
B . CLINICAI CRITER]AFORBRAIN DEATH
l. Absentbrainstemfunction:
a. Fixedanddilatedpupils.
b. No ocular-vestibular
response
to 100ccof icewaterinstilledover30-60
seconds.
c. Absent cornealand phalyngealreflexes including cough on tracheal
suctlon.
d. The absenceofrespiratorymovementduring apneatestingwith an FiO2
of 1.0.
NOTE: The patientshouldhavea normalto mildly elevatedPaCOz,1060 torr, at the initiation of apnea testing and should have "apneic
ventilation" performed for a period of time sufficient to induce a 20 ton
increasein PaCOz.Appropriatesafetystepsare taken and include preoxygenation with 100% orygen and monitoring of arterial blood
pressureand SaOz.Severe hypotensionor desaturationis reason to
terminatetesting.
2. No behavioralor reflex responseto noxious stimuli that imply function
above the level of the foramen magnum. Q.{OTE: Spinal reflexes may be
preserved,andtheir presencedoesnot precludediagnosisofdeath.)
NOIE: Areflexiais commonafterseverebrain injury. However,as the duration
of absentcerebralfunctionlengthens,it becomesmore likely for spinalreflexes
to reappear.
L. Specr
al L ases
1 . Ancillary laboratorytests:Laboratorytestsarenot requiredwherethe diagnosis
is certainandthe clinical criteriaaremet.TheEEG and/orimagingofblood flow
canbe usefuldiagnosticandprognostictestswerethereis uncertaintyaboul
eithertheetiologyor theclinicalfindings.
2. Therapeutic
drug-induced
coma:Barbiturates
andhypothermiacurrently,havea
rolein ameliorating
damage
to thebrainof someseverely
ill patients.
in the
presence
drugintoxication
oftherapeutic
or hypothermia,
thediagnostic
and
prognostic
utility ofthe EEG diminishes.
Absentcerebral
flow asmeasured
by
ho
-..r^.--.{
imagingstudies
will berequiredin theseinstances
andshoul.l
promptlywhenbraindeathis suspected.
D. DeathCertificate
The deathcertificateis to be compleledby the patient'sattendingphysicianor
anotherphvsicianmemberof that service.
CONFIRMATORYSTL]DIESFOR TI]E DETERMINATIONOF
ELECTROCERSBRAIINACTIVITY:
EEG
thevalueofthe EEGin
ofenhancing
involvedshouldbe awareof rnethods
All personnel
personnel
performing
an
inactivity.Thelaboratory
of electrocerebral
the determination
artifactswhichmaybe
technical
EEG shouldbe carefulin notinganypossible
drip-related
ofthesearerespiratory
or intravenous
therecord.Examples
contaminating
personnel,
EKG
artifactsandthe
artifacts,movementaboutthe roomby IntensiveCare
shouldbe awarethattheymaybeableto
like.Also,Intensive
CareUnit personnel
nearthe
theirmovements
ofthe testby restricting
accuracy
thediagnostic
enhance
thattemporarymuscularblockssuch
patientduringthe test.A1lpartiesshouldunderstand
sincethe
invaluable
to theEEGrecording,
areoften
or pancuronium
assuccinylcholine
drugscantemporarilyattenuatemuscleactivitywhich is obscuringthe
ofevenlow
thisfurther,in thepresence
record.To emphasize
electroencephalographic
inactivitymaybe
of electrocerebral
amplitudernuscleartifact,andEEG diagnos;is
such
a diagnosis
maybe
neutomuscular
blockade,
temporary
whereas
with
impossible
madewith certainty.
Thistestis also
perfusion
angiogram.
scanor radionuclide
99mcerebral
Technicium
or
whentheEEGis equivocal
ofbraindeath,specifically
usedin confirmation
pCi/kg,
(200
A bolusof Tc-!r9massodiumpertechnetate
arepresentbarbiturates
in < 3 s. Thepatientis imagedin the
given
intravenously
5
mCi)
is
of
minimum
system.Recordingis begunat
anteriorprojection,usinga gammacamera/computer
ofthe studyis
thetimeof injectionat oneframepersecondfor 60 s.Evaluation
{iom theregions
curvesobtained
visualon theseriesof imagesandontime-activity
In cerebraldeath,the radionuclidecerebral
of interestoverthe cerebralhemispheres.
ofthe
arterialphase(anteriorandmiddle
shows(1) bilateralabsence
angiogram
cerebralarteryterritories,(2) lack ofvisualizationofthe sagittalsinusduringthe
curves,and(4)
venousphase,(3) lackofarterialpeakofcerebraltime-activity
tissuesonl)'.
perfusion
of theexlracranial
Brainstemevokedpotentials.Indicationsarethe sameasfor the EEG,to demonstrate
is absentin brainstem
somatosensory)
thatreactivityto incomingstimuli(auditory,
"flat"
response
in the
wave.A
auditorybrainstem
nuclei,exceptin thefirst (cochlear)
(cochlear
wave)is considered
unequivocal
conduction
presence
ofviableperipheral
ofthe proximityofauditorynucleito vitalcenters.
deathbecause
of cerebral
evidence
evenat maximalstimulusintensity,
If acousticconductionis not demonstrable
potentials
by somatosensory
shouldbecomplemented
evoked
auditorybrainstem
is caused
by
thata flat response
to ruleoutthepossibility
evokedpotentials
brainstem
for
potentials
are
not
a
substituted
the
sensory
evoked
Brainstem
peripheral
deafness.
bpC, Uutdo effectivelycomplementt'heinformationderivedfrom spontaneous
deathis suspected
on clinicalgrounds.
corticalactivitywhencerebral
electrical
of beingfreeof artifact
Brainsternevokedpotentialshavethe advantage
andarelesssensitivethanthe EEGto the effectof CNS depressants.
contamination
thelossofbrainstem
ofactivityfrom theEEGmayprecede
Thedisappearance
aremoresensitiveto the effectof severe
the corticalstt-uctures
because
responses
insults than are the brainstemstructures.Thus, at the time of an isoelectricEEG,
brainstemresponses
may be abnormalthoughnot completelyabsent.In this case,
potentials
serial evoked
are indicatedto provide evidenceof deteriorationin
brainstemfunction.Brainstemevokedpotentialsare recommended
when (1) the
interpretation
ofthe isoelectricEEG is controversial,(2) the EEG is not completely
isoelectric,(agonalstage),or (3) the EIjG is isoelectricbut the elfectsofCNS
depressants
or hypothermiais present.
Transcranial
Ultrasound/ Doppler.Thesestudiesmay be usedwhen other standard
studiesareunavailableor ifthe patientcannotbe readilytransported.
The Doppler
studiesareusedto determinereversalofflow in the major cerebralarteries,indicating
an absenceofcerebral blood flow, specifically exanining the internal carotid artery
andthe middlecerebral
anery