Guidelines for the determination of brain death in infants and children: An update of the 1987 Task Force recommendations*

Abstract

1) Determination of brain 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. Because of insufficient data in the literature, recommendations for preterm infants <37 wks gestational age are not included in this guideline. 2) Hypotension, hypothermia, and metabolic disturbances should be treated and corrected and medications that can interfere with the neurologic examination and apnea testing should be discontinued allowing for adequate clearance before proceeding with these evaluations. 3) Two examinations, including apnea testing with each examination separated by an observation period, are required. Examinations should be performed by different attending physicians. Apnea testing may be performed by the same physician. An observation period of 24 hrs for term newborns (37 wks gestational age) to 30 days of age and 12 hrs for infants and children (>30 days to 18 yrs) is recommended. The first examination determines the child has met the accepted neurologic examination criteria for brain death. The second examination confirms brain death based on an unchanged and irreversible condition. Assessment of neurologic function after cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for ≥24 hrs if there are concerns or inconsistencies in the examination. 4) Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial Paco2 20 mm Hg above the baseline and ≥60 mm Hg with no respiratory effort during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed. 5) Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. Ancillary studies may be used to assist the clinician in making the diagnosis of brain death a) when components of the examination or apnea testing cannot be completed safely as a result of the underlying medical condition of the patient; b) if there is uncertainty about the results of the neurologic examination; c) if a medication effect may be present; or d) 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. In this instance, the observation interval may be shortened and the second neurologic examination and apnea test (or all components that are able to be completed safely) can be performed at any time thereafter. 6) Death is declared when these criteria are fulfilled.

Diagnostic Accuracy of Transcranial Doppler for Brain Death Confirmation: Systematic Review and Meta-Analysis

“…The latest guidelines from the American Academy of Neurology and American Academy of Pediatrics report insufficient evidence for determining brain death with ancillary tests. 3,4 However, ancillary tests remain essential in brain death confirmation when clinical instability prevents safe use of an apnea test 5,6 or barbiturate therapy or hypothermia precludes proper brain death confirmation. 7 In such circumstances, ancillary testing may complement criterion standard testing and confirm brain death.…”

Strategies to optimize kidney recovery and preservation in transplantation: specific aspects in pediatric transplantation

“…If these criteria are met, the results of the clinical examination must remain unchanged during a 24-h period for newborns of 37 weeks gestation age to 30 days, and during a 12-h period for children aged from 30 days to 18 years. Cerebral blood flow or electroencephalography are not required but can be used if the clinical examination cannot be completed, if there is any doubt about the results of the examination, or if medication can interfere with clinical evaluation, or in a reduced observational period [21].…”

Brain Death in a Near-Term Infant: A Case Report

“…10 Due to a lack of specific guidelines for infants younger than 2 months, our NICU's policy for diagnosis of brain death in newborns is not based on a legal standard. To determine brain death, we refer to "An update of the 1987 task force recommendations" revised in 2011 by Nakagawa et al 5 However, this report still lacks a standard for pre term babies. It is especially difficult to confirm brain death in premature babies in the NICU, because evaluation of brainstem function or level of consciousness in preterm babies under 37 weeks of gestational age is an uncertain and challenging process.…”