Document Detail


Guidelines for the determination of brain death in infants and children: An update of the 1987 Task Force recommendations.
MedLine Citation:
PMID:  21849823     Owner:  NLM     Status:  Publisher    
Abstract/OtherAbstract:
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.
Authors:
Thomas A Nakagawa; Stephen Ashwal; Mudit Mathur; Mohan R Mysore; Derek Bruce; Edward E Conway; Susan E Duthie; Shannon Hamrick; Rick Harrison; Andrea M Kline; Daniel J Lebovitz; Maureen A Madden; Vicki L Montgomery; Jeffrey M Perlman; Nancy Rollins; Sam D Shemie; Amit Vohra; Jacqueline A Williams-Phillips; ; ;
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Publication Detail:
Type:  JOURNAL ARTICLE    
Journal Detail:
Title:  Critical care medicine     Volume:  39     ISSN:  1530-0293     ISO Abbreviation:  -     Publication Date:  2011 Sep 
Date Detail:
Created Date:  2011-8-18     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0355501     Medline TA:  Crit Care Med     Country:  -    
Other Details:
Languages:  ENG     Pagination:  2139-2155     Citation Subset:  -    
Affiliation:
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.
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