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

Nakagawa, Thomas A. MD, FAAP, FCCM; Ashwal, Stephen MD, FAAP; Mathur, Mudit MD, FAAP; Mysore, Mohan R. MD, FAAP, FCCM; Bruce, Derek MD; Conway, Edward E. Jr MD, FCCM; Duthie, Susan E. MD; Hamrick, Shannon MD; Harrison, Rick MD; Kline, Andrea M. RN, MS, FCCM; Lebovitz, Daniel J. MD; Madden, Maureen A. MSN, FCCM; Montgomery, Vicki L. MD, FCCM; Perlman, Jeffrey M. MBChB, FAAP; Rollins, Nancy MD, FAAP; Shemie, Sam D. MD; Vohra, Amit MD, FAAP; Williams-Phillips, Jacqueline A. MD, FAAP, FCCM; Society of Critical Care Medicine; the Section on Critical Care and Section on Neurology of the American Academy of Pediatrics; the Child Neurology Society

doi: 10.1097/CCM.0b013e31821f0d4f
Special Pediatric Neurologic Critical Care Article

Objective: To review and revise the 1987 pediatric brain death guidelines.

Methods: Relevant literature was reviewed. Recommendations were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Conclusions and Recommendations: 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.

Professor (TAN), Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Director, Pediatric Critical Care, Brenner Children's Hospital at Wake Forest University Baptist Medical Center, Winston-Salem, NC; Professor of Pediatrics (SA), Department of Pediatrics, Chief, Division of Child Neurology, Loma Linda University School of Medicine, Loma Linda, CA; Associate Professor of Pediatrics (MM), Division of Pediatric Critical Care, Loma Linda University School of Medicine, Loma Linda, CA; Professor of Pediatrics (MRM), University of Nebraska College of Medicine, Director, Pediatric Critical Care, Children's Hospital and Medical Center, Omaha, NE; Professor of Neurosurgery and Pediatrics (DB), Children's National Medical Center, Washington, DC; Professor of Pediatrics (EEC), Beth Israel Medical Center, Hartsdale, NY; Pediatric Critical Care (SED), Rady Children's Hospital-San Diego, San Diego, CA; Assistant Professor of Pediatrics (SH), Emory University, Children's Healthcare of Atlanta, Atlanta, GA; Professor of Pediatrics (RH), David Geffen School of Medicine UCLA, Mattel Children's Hospital, UCLA, Los Angeles, CA; Nurse Practitioner (AMK), Riley Hospital for Children, Indianapolis, IN; Associate Professor of Pediatrics (DJL), Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Children's Hospital, Cleveland, OH; Assistant Professor of Pediatrics (MAM), Robert Wood Johnson Medical School, Pediatric Critical Care Nurse Practitioner, Bristol-Myers Squibb Children's Hospital, New Brunswick, NJ; Professor of Pediatrics (VLM), University of Louisville, Chief, Division of Pediatric Critical Care Medicine, Medical Director, Patient Safety Officer, Norton Healthcare Kosair Children's Hospital, Louisville, KY; Professor of Pediatrics (JMP), Weill Cornell Medical College, New York, NY; Professor of Pediatrics and Radiology (NR), Children's Medical Center, Southwestern University, Dallas, TX; Professor of Pediatrics (SDS), Montreal Children's Hospital, Montreal, Canada; Assistant Professor of Pediatrics (AV), Wright State University, Pediatric Critical Care, Children's Medical Center, Dayton, OH; Associate Professor of Pediatrics (JAW-P), UMDNJ-Robert Wood Johnson Medical School, Director, Pediatric Intensive Care Unit, Bristol-Myers Squibb Children's Hospital, New Brunswick, NJ.

The American College of Critical Care Medicine (ACCM), which honors individuals for their achievements and contributions to multidisciplinary critical care medicine, is the consultive body of the Society of Critical Care Medicine (SCCM) that possesses recognized expertise in the practice of critical care. The College has developed administrative guidelines and clinical practice parameters for the critical care practitioner. New guidelines and practice parameters are continually developed, and current ones are systematically reviewed and revised.

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: tnakagaw@wfubmc.edu

© 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins