August 31, 2011.
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.
"[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.
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
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.