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Lewis A, Kirschen MP, Greer DM. Author Response: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM. Neurology 2024; 102:e209370. [PMID: 38648607 DOI: 10.1212/wnl.0000000000209370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
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Gambardella I, Nappi F, Worku B, Tranbaugh RF, Ibrahim AM, Balaram SK, Bernat JL. Taking the pulse of brain death: A meta-analysis of the natural history of brain death with somatic support. Eur J Neurol 2024; 31:e16243. [PMID: 38375732 DOI: 10.1111/ene.16243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/02/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND PURPOSE The conceptualization of brain death (BD) was pivotal in the shaping of judicial and medical practices. Nonetheless, media reports of alleged recovery from BD reinforced the criticism that this construct is a self-fulfilling prophecy (by treatment withdrawal or organ donation). We meta-analyzed the natural history of BD when somatic support (SS) is maintained. METHODS Publications on BD were eligible if the following were reported: aggregated data on its natural history with SS; and patient-level data that allowed censoring at the time of treatment withdrawal or organ donation. Endpoints were as follows: rate of somatic expiration after BD with SS; BD misdiagnosis, including "functionally brain-dead" patients (FBD; i.e. after the pronouncement of brain-death, ≥1 findings were incongruent with guidelines for its diagnosis, albeit the lethal prognosis was not altered); and length and predictors of somatic survival. RESULTS Forty-seven articles were selected (1610 patients, years: 1969-2021). In BD patients with SS, median age was 32.9 years (range = newborn-85 years). Somatic expiration followed BD in 99.9% (95% confidence interval = 89.8-100). Mean somatic survival was 8.0 days (range = 1.6 h-19.5 years). Only age at BD diagnosis was an independent predictor of somatic survival length (coefficient = -11.8, SE = 4, p < 0.01). Nine BD misdiagnoses were detected; eight were FBD, and one newborn fully recovered. No patient ever recovered from chronic BD (≥1 week somatic survival). CONCLUSIONS BD diagnosis is reliable. Diagnostic criteria should be fine-tuned to avoid the small incidence of misdiagnosis, which nonetheless does not alter the prognosis of FBD patients. Age at BD diagnosis is inversely proportional to somatic survival.
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Affiliation(s)
| | - Francesco Nappi
- Cardiac Surgery Center, Cardiologique du Nord de Saint-Denis, Paris, France
| | - Berhane Worku
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Robert F Tranbaugh
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Aminat M Ibrahim
- Department of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Sandhya K Balaram
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, New York, USA
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Lewis A. An Update on Brain Death/Death by Neurologic Criteria since the World Brain Death Project. Semin Neurol 2024. [PMID: 38621707 DOI: 10.1055/s-0044-1786020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
The World Brain Death Project (WBDP) is a 2020 international consensus statement that provides historical background and recommendations on brain death/death by neurologic criteria (BD/DNC) determination. It addresses 13 topics including: (1) worldwide variance in BD/DNC, (2) the science of BD/DNC, (3) the concept of BD/DNC, (4) minimum clinical criteria for BD/DNC determination, (5) beyond minimum clinical BD/DNC determination, (6) pediatric and neonatal BD/DNC determination, (7) BD/DNC determination in patients on ECMO, (8) BD/DNC determination after treatment with targeted temperature management, (9) BD/DNC documentation, (10) qualification for and education on BD/DNC determination, (11) somatic support after BD/DNC for organ donation and other special circumstances, (12) religion and BD/DNC: managing requests to forego a BD/DNC evaluation or continue somatic support after BD/DNC, and (13) BD/DNC and the law. This review summarizes the WBDP content on each of these topics and highlights relevant work published from 2020 to 2023, including both the 192 citing publications and other publications on BD/DNC. Finally, it reviews questions for future research related to BD/DNC and emphasizes the need for national efforts to ensure the minimum standards for BD/DNC determination described in the WBDP are included in national BD/DNC guidelines and due consideration is given to the recommendations about social and legal aspects of BD/DNC determination.
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Affiliation(s)
- Ariane Lewis
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, NYU Langone Medical Center, New York
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Kirschen MP, Lewis A, Greer DM. The 2023 American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine Pediatric and Adult Brain Death/Death by Neurologic Criteria Determination Consensus Guidelines: What the Critical Care Team Needs to Know. Crit Care Med 2024; 52:376-386. [PMID: 37921516 DOI: 10.1097/ccm.0000000000006099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Guidelines for brain death/death by neurologic criteria (BD/DNC) determination were revised to provide a consistent and updated approach to BD/DNC evaluation across all ages by the American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine. This article is intended to complement the guidelines and highlight aspects relevant to the critical care community; the actual guidelines should be used to update hospital protocols and dictate clinical practice. Because BD/DNC evaluations are conducted in the ICU, it is essential for members of the critical care community to familiarize themselves with these guidelines. The fundamental concept of BD/DNC has not changed; BD/DNC is permanent loss of function of the brain as a whole, including the brain stem, resulting in coma, brainstem areflexia, and apnea in the setting of an adequate stimulus. The BD/DNC evaluation requires a sufficient observation period to ensure there is no chance of recovery, followed by exclusion of potentially confounding conditions like hypothermia, hypotension, severe metabolic disturbances, or medication effects. Specific guidance is provided for patients who were treated with therapeutic hypothermia or medical or surgical interventions to manage intracranial hypertension. The guidelines outline a structured and meticulous neurologic examination and detail the responses consistent with BD/DNC. A protocol is provided for how to safely perform apnea testing, including modifications needed for patients on extracorporeal membrane oxygenation. Controversial issues such as consent, BD/DNC evaluation in pregnancy, preservation of neuroendocrine function, and primary posterior fossa injuries are addressed. The ultimate goal is to ensure a consistent and accurate approach to BD/DNC evaluation in patients of all ages, fostering public trust in the medical community's ability to determine death. By adhering to these guidelines, critical care clinicians can confidently navigate the challenging aspects of BD/DNC determination.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Critical Care Medicine, Neurology, and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY
| | - David M Greer
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA
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Greer DM, Kirschen MP, Lewis A, Gronseth GS, Rae-Grant A, Ashwal S, Babu MA, Bauer DF, Billinghurst L, Corey A, Partap S, Rubin MA, Shutter L, Takahashi C, Tasker RC, Varelas PN, Wijdicks E, Bennett A, Wessels SR, Halperin JJ. Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline. Neurology 2023; 101:1112-1132. [PMID: 37821233 PMCID: PMC10791061 DOI: 10.1212/wnl.0000000000207740] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/28/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The purpose of this guideline is to update the 2010 American Academy of Neurology (AAN) brain death/death by neurologic criteria (BD/DNC) guideline for adults and the 2011 American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine guideline for infants and children and to clarify the BD/DNC determination process by integrating guidance for adults and children into a single guideline. Updates in this guideline include guidance related to conducting the BD/DNC evaluation in the context of extracorporeal membrane oxygenation, targeted temperature management, and primary infratentorial injury. METHODS A panel of experts from multiple medical societies developed BD/DNC recommendations. Because of the lack of high-quality evidence on the subject, a novel, evidence-informed formal consensus process was used. This process relied on the panel experts' review and detailed knowledge of the literature surrounding BD/DNC to guide the development of preliminary recommendations. Recommendations were formulated and voted on, using a modified Delphi process, according to the 2017 AAN Clinical Practice Guideline Process Manual. MAJOR RECOMMENDATIONS Eighty-five recommendations were developed on the following: (1) general principles for the BD/DNC evaluation, (2) qualifications to perform BD/DNC evaluations, (3) prerequisites for BD/DNC determination, (4) components of the BD/DNC neurologic examination, (5) apnea testing as part of the BD/DNC evaluation, (6) ancillary testing as part of the BD/DNC evaluation, and (7) special considerations for BD/DNC determination.
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Affiliation(s)
- David M Greer
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Matthew P Kirschen
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Ariane Lewis
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Gary S Gronseth
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Alexander Rae-Grant
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Stephen Ashwal
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Maya A Babu
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - David F Bauer
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Lori Billinghurst
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Amanda Corey
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Sonia Partap
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Michael A Rubin
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Lori Shutter
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Courtney Takahashi
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Robert C Tasker
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Panayiotis Nicolaou Varelas
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Eelco Wijdicks
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Amy Bennett
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Scott R Wessels
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - John J Halperin
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
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6
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Lewis A, Kirschen MP, Greer D. The 2023 AAN/AAP/CNS/SCCM Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline: A Comparison With the 2010 and 2011 Guidelines. Neurol Clin Pract 2023; 13:e200189. [PMID: 37829552 PMCID: PMC10567121 DOI: 10.1212/cpj.0000000000200189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 07/07/2023] [Indexed: 10/14/2023]
Abstract
In collaboration with the American Academy of Pediatrics, Child Neurology Society, and Society for Critical Care Medicine, the American Academy of Neurology formulated an updated, evidence-informed consensus-based guideline for pediatric and adult brain death/death by neurologic criteria (BD/DNC) determination. In comparison with the prior guidelines, the revisions and additions in this guideline, which are summarized in this review, are intended to (1) ensure recommendations are conservative, yet practical, and emphasize circumstances in which BD/DNC determination should be delayed or deferred, so as to minimize the risk of a false-positive BD/DNC determination; and (2) provide guidance about aspects of BD/DNC determination that clinicians find challenging and/or controversial. We hope that clinicians throughout the United States will use this information to revise their hospital BD/DNC determination policies to conform to the standardized process for BD/DNC determination described in the new guideline, to ensure that every BD/DNC evaluation is consistent and accurate.
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Affiliation(s)
- Ariane Lewis
- NYU Langone Medical Center (AL), NY; The Children's Hospital of Philadelphia (MPK), PA; Boston University School of Medicine and Boston Medical Center (DG), MA
| | - Matthew P Kirschen
- NYU Langone Medical Center (AL), NY; The Children's Hospital of Philadelphia (MPK), PA; Boston University School of Medicine and Boston Medical Center (DG), MA
| | - David Greer
- NYU Langone Medical Center (AL), NY; The Children's Hospital of Philadelphia (MPK), PA; Boston University School of Medicine and Boston Medical Center (DG), MA
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7
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Robbins NM. What Is the Ideal Brain Criterion of Death? Clinical and Practical Considerations: The UDDA Revision Series. Neurology 2023; 101:83-85. [PMID: 37429724 DOI: 10.1212/wnl.0000000000207335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 03/07/2023] [Indexed: 07/12/2023] Open
Affiliation(s)
- Nathaniel M Robbins
- From the Geisel School of Medicine at Dartmouth (N.M.R.), Hanover; and Dartmouth-Hitchcock Medical Center (N.M.R.), Lebanon, NH.
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8
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LaRovere KL, Luchette M, Akhondi-Asl A, DeSouza BJ, Tasker RC, Mehta NM, Geva A. Heart Rate Change as a Potential Digital Biomarker of Brain Death in Critically Ill Children With Acute Catastrophic Brain Injury. Crit Care Explor 2023; 5:e0908. [PMID: 37151893 PMCID: PMC10158912 DOI: 10.1097/cce.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
Bedside measurement of heart rate (HR) change (HRC) may provide an objective physiologic marker for when brain death (BD) may have occurred, and BD testing is indicated in children. OBJECTIVES To determine whether HRC, calculated using numeric HR measurements sampled every 5 seconds, can identify patients with BD among patients with catastrophic brain injury (CBI). DESIGN SETTING AND PARTICIPANTS Single-center, retrospective study (2008-2020) of critically ill children with acute CBI. Patients with CBI had a neurocritical care consultation, were admitted to an ICU, had acute neurologic injury on presentation or during hospitalization based on clinical and/or imaging findings, and died or survived with Glasgow Coma Scale (GCS) less than 13 at hospital discharge. Patients meeting BD criteria (BD group) were compared with those with cardiopulmonary death (CD group) or those who survived to discharge. MAIN OUTCOMES AND MEASURES HRC was calculated as the interquartile range of HR divided by median HR using 5-minute windows with 50% overlap for up to 5 days before death or end of recording. HRC was compared among the BD, CD, and survivor groups. RESULTS Of 96 patients with CBI (69% male, median age 4 years), 28 died (8 BD, 20 CD) and 20 survived (median GCS 9 at discharge). Within 24 hours before death, HRC was lower in BD compared with CD patients or survivors (0.01 vs 0.03 vs 0.04, p = 0.001). In BD patients, HRC decreased at least 1 day before death. HRC discriminated BD from CD patients and survivors with 90% sensitivity, 70% specificity, 44% positive predictive value, 96% negative predictive value (area under the receiver operating characteristic curve 0.88, 95% CI, 0.80-0.93). CONCLUSIONS AND RELEVANCE HRC is a novel digital biomarker that, with further validation, may be useful as a classifier for BD in the overall course of patients with CBI.
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Affiliation(s)
- Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Boston Children's Hospital, Boston, MA
| | - Matthew Luchette
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Boston Children's Hospital, Boston, MA
| | - Alireza Akhondi-Asl
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Boston Children's Hospital, Boston, MA
| | - Bradley J DeSouza
- Department of Critical Care Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Boston Children's Hospital, Boston, MA
| | - Alon Geva
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Boston Children's Hospital, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
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9
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Pope TM, Chandler JA, Hartwick M. Consent for determination of death by neurologic criteria in Canada: an analysis of legal and ethical authorities, and consensus-based working group recommendations. Can J Anaesth 2023; 70:570-584. [PMID: 37131032 PMCID: PMC10153780 DOI: 10.1007/s12630-023-02430-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 05/04/2023] Open
Abstract
This article addresses the following question: should physicians obtain consent from the patient (through an advance directive) or their surrogate decision-maker to perform the assessments, evaluations, or tests necessary to determine whether death has occurred according to neurologic criteria? While legal bodies have not yet provided a definitive answer, significant legal and ethical authority holds that clinicians are not required to obtain family consent before making a death determination by neurologic criteria. There is a near consensus among available professional guidelines, statutes, and court decisions. Moreover, prevailing practice does not require consent to test for brain death. While arguments for requiring consent have some validity, proponents cannot surmount weightier considerations against imposing a consent requirement. Nevertheless, even though clinicians and hospitals may not be legally required to obtain consent, they should still notify families about their intent to determine death by neurologic criteria and offer temporary reasonable accommodations when feasible. This article was developed with the legal/ethics working group of the project, A Brain-Based Definition of Death and Criteria for its Determination After Arrest of Circulation or Neurologic Function in Canada developed in collaboration with the Canadian Critical Care Society, Canadian Blood Services, and the Canadian Medical Association. The article is meant to provide support and context for this project and is not intended to specifically advise physicians on legal risk, which in any event is likely jurisdiction dependent because of provincial or territorial variation in the laws. The article first reviews and analyzes ethical and legal authorities. It then offers consensus-based recommendations regarding consent for determination of death by neurologic criteria in Canada.
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Affiliation(s)
- Thaddeus M Pope
- Mitchell Hamline School of Law, 875 Summit Avenue, Saint Paul, MN, 55105, USA.
| | - Jennifer A Chandler
- Faculties of Law and Medicine, Bertram Loeb Research Chair, University of Ottawa, Ottawa, ON, Canada
| | - Michael Hartwick
- Department of Medicine, Divisions of Critical Care and Palliative Medicine, University of Ottawa, Ottawa, ON, Canada
- Trillium Gift of Life, Ottawa, ON, Canada
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10
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Zuckier LS, McKinnon NK. Ancillary radionuclide perfusion studies in the determination of death by neurologic criteria: methods, interpretation, and lexicon-a user guide for the clinician. Can J Anaesth 2023; 70:771-780. [PMID: 37131034 PMCID: PMC10202972 DOI: 10.1007/s12630-023-02420-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/22/2022] [Accepted: 08/29/2022] [Indexed: 05/04/2023] Open
Abstract
Radionuclide perfusion studies have an established ancillary role in determination of death by neurologic criteria (DNC). While critically important, these examinations are not well understood by individuals outside of the imaging specialties. The purpose of this review is to clarify relevant concepts and nomenclature and provide a lexicon of relevant terminology of value to non-nuclear medicine practitioners who wish to better understand these examinations. Radionuclides were first employed to evaluate cerebral blood flow in 1969. Radionuclide DNC examinations that use lipophobic radiopharmaceuticals (RPs) entail a flow phase followed immediately by blood pool images. On flow imaging, presence of intracranial activity within the arterial vasculature is scrutinized following arrival of the RP bolus into the neck. Lipophilic RPs designed for functional brain imaging were introduced to nuclear medicine in the 1980s and were engineered to cross the blood-brain-barrier and be retained in the parenchyma. The lipophilic RP 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) was first used as an ancillary investigation in DNC in 1986. Examinations using lipophilic RPs entail both flow and parenchymal phase images. According to some guidelines, parenchymal phase uptake should be assessed by tomographic imaging, while other investigators consider simple planar imaging sufficient. Findings of perfusion on either the flow or parenchymal phase of the examination effectively precludes DNC. If the flow phase is omitted or somehow compromised, the parenchymal phase remains sufficient for DNC. A priori, parenchymal phase imaging is superior to flow phase imaging for several reasons and lipophilic RPs are favoured over lipophobic RPs in that both flow and parenchymal phase imaging are performed. Disadvantages of lipophilic RPs are increased cost and the need to procure them from a central laboratory, which can prove difficult, especially outside usual working hours. According to most current guidelines, both lipophilic and lipophobic RP categories are acceptable for use in ancillary investigations in DNC, with a growing overt preference for studies using the lipophilic RPs based on their ability to capture the parenchymal phase. The new adult and pediatric Canadian recommendations favour use of lipophilic RPs to variable degrees, specifically 99mTc-HMPAO, the lipophilic moiety which has undergone the greatest validation. Although ancillary use of radiopharmaceuticals is quite settled in multiple DNC guidelines and best practices, several areas of further research remain open to investigation. Examens auxiliaires de perfusion nucléaire pour la détermination du décès selon des critères neurologiques : méthodes, interprétation et lexique-un guide de l'utilisateur à l'intention du clinicien.
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Affiliation(s)
- Lionel S Zuckier
- Division of Nuclear Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
- Department of Radiology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nicole K McKinnon
- Department of Critical Care, Hospital for Sick Children (SickKids), Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Neuroscience and Mental Health, Peter Gilgan Center for Research and Learning, Toronto, ON, Canada
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11
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Bluhme E, Henckel E, Jorns C. Potential of neonatal organ donation and outcome after transplantation. Pediatr Transplant 2023; 27:e14486. [PMID: 36792069 DOI: 10.1111/petr.14486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 02/17/2023]
Abstract
Organ transplantation is limited by access to suitable organs. Infant recipient waitlist mortality is increased due to the scarcity of size-matched organs. Neonatal organ donors have been proposed as an underutilized source of donor organs. However, the literature on the actual prevalence and outcome of neonatal organ donation and transplantation is fragmented and not well analyzed. This literature review aims to summarize the available literature on the potential of neonatal organ donation and to analyze published cases of neonatal organ transplantation. A systematic search of the Medline and Cochrane databases yielded 2964 articles, which were screened for eligibility. In total, 86 articles were considered eligible, of which 34 were included in the literature review: 8 articles describing the potential of neonatal organ donation programs, and 26 articles describing clinical transplantation. Current evidence suggests there is a large pool of potential neonatal organ donors. In contrast, the literature on neonatal organ donor utilization is sparse. However, case series of successful kidney, heart, liver, hepatocyte, and multivisceral transplantation using organs from neonatal donors are summarized. Although good posttransplant organ function was achieved, the use of neonatal organs is associated with increased risk of thrombosis in both kidney and liver transplantation. Neonatal organ donation is a promising alternative for expanding the current donor pool. Experience is limited, but reported patient and graft survival are acceptable and more research on the subject is warranted.
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Affiliation(s)
- Emil Bluhme
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Ewa Henckel
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Carl Jorns
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Transplantation, Karolinska University Hospital, Stockholm, Sweden
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Silva A, Arora S, Dhanani S, Rochon A, Giorno LP, Jackson E, Hornby L, Latifi M, Lotherington K, Luctkar-Flude M, Petry S, Wilson L, Silva E Silva V. Quality improvement tools to manage deceased organ donation processes: a scoping review. BMJ Open 2023; 13:e070333. [PMID: 36731923 PMCID: PMC9896188 DOI: 10.1136/bmjopen-2022-070333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To collate and summarise the literature on the quality improvement tools that have been developed for deceased organ donation processes after circulatory determination of death and neurological determination of death. DESIGN Scoping review using the Joanna Briggs Institute framework. DATA SOURCES We searched for published (MEDLINE, Embase, PsycINFO, CINAHL, Web of Science) and unpublished literature (organ donation organisation websites worldwide). The search was initially conducted on 17 July 2021 and updated on 1 June 2022. Included articles discussed the creation and/or use of quality improvement tools to manage deceased organ donation processes. Two independent reviewers screened the references, extracted and analysed the data. RESULTS 40 references were included in this review, and most records were written in English (n=38), originated in Canada (n=21), published between 2016 and 2022 (n=22), and were specific for donation after neurological determination of death (n=20). The tools identified included checklists, algorithms, flow charts, charts, pathways, decision tree maps and mobile apps. These tools were applied in the following phases of the organ donation process: (1) potential donor identification, (2) donor referral, (3) donor assessment and risk, (4) donor management, (5) withdrawal of life-sustaining measures, (6) death determination, (7) organ retrieval and (8) overall organ donation process. CONCLUSIONS We conducted a thorough investigation of the available quality improvement tools for deceased organ donation processes. The existing evidence lacks details in the report of methods used for development, testing and impact of these tools, and we could not locate tools specific for some phases of the organ donation process. Lastly, by mapping existing tools, we aim to facilitate both clinician choices among available tools, as well as research work building on existing knowledge.
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Affiliation(s)
- Amina Silva
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Sonny Dhanani
- Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Andrea Rochon
- School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - Luciana P Giorno
- School of Nursing, Federal University of the ABC, Santo Andre, SP, Brazil
| | - Elayne Jackson
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Laura Hornby
- Research Institute, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Marzieh Latifi
- Sina Organ procurement unit, Tehran, Iran (the Islamic Republic of)
| | | | | | - Stefany Petry
- School of Nursing, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
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13
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Hatami S, Conway J, Freed DH, Urschel S. Thoracic organ donation after circulatory determination of death. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2022.100125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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14
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Long RF, Kingsley DJ, Derrington DSF. The Shifting Landscape of Death by Neurologic Criteria in Pediatrics: Current Controversies and Persistent Questions. Semin Pediatr Neurol 2023; 45:101034. [PMID: 37003632 DOI: 10.1016/j.spen.2023.101034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
Since the concept of death by neurologic criteria (DNC) or "brain death" was articulated by the Harvard Ad Hoc Committee in 1968, efforts to establish and uphold DNC as equivalent to biologic death have been supported through federal and state legislation, professional guidelines, and hospital policies. Despite these endeavors, DNC remains controversial among bioethics scholars and clinicians and is not universally accepted by patient families and the public. In this focused review, we outline the current points of contention surrounding the diagnosis of DNC in pediatric patients. These include physiologic, legal, and philosophical inconsistencies in the definition of DNC, controversy regarding the components of the clinical exam, variability in clinical practice, and ethical concerns regarding justice and role of informed consent. By better understanding these controversies, clinicians may serve families grappling with the diagnosis of DNC more effectively, compassionately, and equitably.
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15
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Mazzola MA, Russell JA. Neurology ethics at the end of life. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:235-257. [PMID: 36599511 DOI: 10.1016/b978-0-12-824535-4.00012-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ethical challenges in medical decision making are commonly encountered by clinicians caring for patients afflicted by neurological injury or disease at the end of life (EOL). In many of these cases, there are conflicting opinions as to what is right and wrong originating from multiple sources. There is a particularly high prevalence of impaired patient judgment and decision-making capacity in this population that may result in a misrepresentation of their premorbid values and goals. Conflict may originate from a discordance between what is legal or from stakeholders who view and value life and existence differently from the patient, at times due to religious or cultural influences. Promotion of life, rather than preservation of existence, is the goal of many patients and the foundation on which palliative care is built. Those who provide EOL care, while being respectful of potential cultural, religious, and legal stakeholder perspectives, must at the same time recognize that these perspectives may conflict with the optimal ethical course to follow. In this chapter, we will attempt to review some of the more notable ethical challenges that may arise in the neurologically afflicted at the EOL. We will identify what we believe to be the most compelling ethical arguments both in support of and opposition to specific EOL issues. At the same time, we will consider how ethical analysis may be influenced by these legal, cultural, and religious considerations that commonly arise.
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Abstract
OBJECTIVE The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. BACKGROUND While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. METHODS We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. RESULTS Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. CONCLUSIONS Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.
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Marron JM. Pediatric Brain Death Testing Over Parental Objections: Not an Ethically Preferable Option. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:90-93. [PMID: 36595010 PMCID: PMC9813910 DOI: 10.1080/15265161.2022.2146792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- Jonathan M Marron
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School
- Center for Bioethics, Harvard Medical School
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18
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Slak P, Pušnik L, Plut D. Contrast-Enhanced Ultrasound (CEUS) as an Ancillary Imaging Test for Confirmation of Brain Death in an Infant: A Case Report. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101525. [PMID: 36291460 PMCID: PMC9600316 DOI: 10.3390/children9101525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022]
Abstract
The practices for determining brain death are based on clinical criteria and vary immensely across countries. Cerebral angiography and perfusion scintigraphy are the most commonly used ancillary imaging tests for brain death confirmation in children; however, they both share similar shortcomings. Hence, contrast-enhanced ultrasound (CEUS) as a relatively inexpensive, easily accessible, and easy-to-perform technique has been proposed as an ancillary imaging test for brain death confirmation. CEUS has established itself as a favourable and widely used diagnostic imaging method in many different areas, but its application in delineating brain pathologies still necessities further validation. Herein, we present a case report of a 1-year-old polytraumatised patient in whom CEUS was applied as an ancillary imaging test for confirmation of brain death. As CEUS has not been validated as an ancillary test for brain death confirmation, the diagnosis was additionally confirmed with cerebral perfusion scintigraphy.
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Affiliation(s)
- Peter Slak
- Clinical Radiology Institute, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana 1000, Slovenia
| | - Luka Pušnik
- Faculty of Medicine, University of Ljubljana, Ljubljana 1000, Slovenia
| | - Domen Plut
- Clinical Radiology Institute, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana 1000, Slovenia
- Correspondence:
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Abstract
PURPOSE OF REVIEW Brain death, also known as death by neurologic criteria (DNC), is a well-established concept. In this article, we present a short history of the concept and give an overview of recent changes and a practical update on diagnosis and definitions of brain death/DNC. Unresolved issues will be discussed. RECENT FINDINGS There is variability in brain death/DNC determination worldwide. In recent years, successful attempts have been made to harmonize these criteria and, consequently, to improve public trust in the process and diagnosis. An international multidisciplinary collaboration has been created and it has published minimum criteria, provided guidance for professionals and encouragement to revise or develop guidelines on brain death/DNC worldwide. SUMMARY There are two sets of criteria for declaration of death. First, if there is neither cardiac output nor respiratory effort, then cardiopulmonary criteria are used. Second, if both the cerebrum and brainstem have completely and permanently lost all functions, and there is a persistent coma, absent brainstem reflexes and no spontaneous respiratory effort, death can be declared on the basis of brain death/DNC. Although attempts to formulate uniform criteria are ongoing, consensus has been reached on the minimum criteria. Some inconsistencies and questions remain.
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20
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Coppler PJ, Flickinger KL, Darby JM, Doshi A, Guyette FX, Faro J, Callaway CW, Elmer J. Early risk stratification for progression to death by neurological criteria following out-of-hospital cardiac arrest. Resuscitation 2022; 179:248-255. [PMID: 35914657 DOI: 10.1016/j.resuscitation.2022.07.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/27/2022] [Accepted: 07/22/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Some patients resuscitated from out-of-hospital cardiac arrest (OHCA) progress to death by neurological criteria (DNC). We hypothesized that initial brain imaging, electroencephalography (EEG), and arrest characteristics predict progression to DNC. METHODS We identified comatose OHCA patients from January 2010 to February 2020 treated at a single quaternary care facility in Western Pennsylvania. We abstracted demographics and arrest characteristics; Pittsburgh Cardiac Arrest Category, initial motor exam and pupillary light reflex; initial brain computed tomography (CT) grey-to-white ratio (GWR), sulcal or basal cistern effacement; initial EEG background and suppression ratio. We used two modeling approaches: fast and frugal tree (FFT) analysis to create an interpretable clinical risk stratification tool and ridge regression for comparison. We used bootstrapping to randomly partition cases into 80% training and 20% test sets and evaluated test set sensitivity and specificity. RESULTS We included 1,569 patients, of whom 147 (9%) had diagnosed DNC. Across bootstrap samples, >99% of FFTs included three predictors: sulcal effacement, and in cases without sulcal effacement, the combination of EEG background suppression and GWR ≤ 1.23. This tree had mean sensitivity and specificity of 87% and 81%. Ridge regression with all available predictors had mean sensitivity 91 % and mean specificity 83%. Subjects falsely predicted as likely to progress to DNC generally died of rearrest or withdrawal of life sustaining therapies due to poor neurological prognosis. Two of these cases awakened from coma during the index hospitalization. CONCLUSIONS Sulcal effacement on presenting brain CT or EEG suppression with GWR ≤ 1.23 predict progression to DNC after OHCA.
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Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | | | - Joseph M Darby
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ankur Doshi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John Faro
- Department of Family Medicine, Soin Medical Center - Kettering Health Network, Beavercreek, OH, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
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21
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Krawiec C, Mysore MR, Mathur M, Fang X, Zhou S, Thomas NJ, Nakagawa TA. Impact of the Updated Guideline for Pediatric Brain Death Determination on Current Practice. J Child Neurol 2022; 37:553-561. [PMID: 35603748 PMCID: PMC9177504 DOI: 10.1177/08830738221047668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: A guideline to determine pediatric brain death was updated in 2011. It is unknown how pediatric intensivists have accepted and adopted the revised guideline into clinical practice. Methods: We surveyed US pediatric critical care attending physicians July 2013 to September 2013 and February 2020 to May 2020. Brain death testing practices and utilization of the 2011 pediatric and neonatal brain death guideline were assessed. Results: The 2020 respondents found that the revised pediatric brain death guideline were useful in clinical practice (93.7% vs 83.3%, P = .0484) and provided more consistency and clarity (73.2% vs 63.1%, P = .0462) when compared to 2013 respondents. Conclusion: This study demonstrates that with defined criteria, survey participants reported increased clarity and consistency. Findings from our study indicate that in clinical practice there is no significant deviation from the minimum requirements to determine brain death in children as outlined in the 2011 guideline.
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Affiliation(s)
- Conrad Krawiec
- Penn State Children’s Hospital, Pediatric Critical Care Medicine, Department of Pediatrics, 500 University Drive, Hershey, PA, USA
| | - Mohan R. Mysore
- Pediatric Critical Care, Boys Town National Research Hospital, Boys Town, NE, USA
| | - Mudit Mathur
- Pediatric Critical Care, Southern California Permanente Medical Group, Kaiser Permanente School of Medicine, Pasadena, CA, USA
| | - Xinying Fang
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Shouhao Zhou
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Neal J. Thomas
- Penn State Children’s Hospital, Pediatric Critical Care Medicine, Department of Pediatrics, 500 University Drive, Hershey, PA, USA,Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Thomas A. Nakagawa
- Department of Pediatrics, Division of Critical Care Medicine, University of Florida College of Medicine. Jacksonville, FL, USA
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22
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Zuckier LS. Radionuclide Evaluation of Brain Death in the Post-McMath Era, epilogue and enigmata. J Nucl Med 2022; 63:1323-1325. [PMID: 35589410 DOI: 10.2967/jnumed.122.263972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/11/2022] [Indexed: 11/16/2022] Open
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23
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Pope TM. Rebuttal From Dr Pope. Chest 2022; 161:1148-1149. [PMID: 35526890 DOI: 10.1016/j.chest.2021.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022] Open
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Spears W, Mian A, Greer D. Brain death: a clinical overview. J Intensive Care 2022; 10:16. [PMID: 35292111 PMCID: PMC8925092 DOI: 10.1186/s40560-022-00609-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/06/2022] [Indexed: 01/01/2023] Open
Abstract
Brain death, also commonly referred to as death by neurologic criteria, has been considered a legal definition of death for decades. Its determination involves many considerations and subtleties. In this review, we discuss the philosophy and history of brain death, its clinical determination, and special considerations. We discuss performance of the main clinical components of the brain death exam: assessment of coma, cranial nerves, motor testing, and apnea testing. We also discuss common ancillary tests, including advantages and pitfalls. Special discussion is given to extracorporeal membrane oxygenation, target temperature management, and determination of brain death in pediatric populations. Lastly, we discuss existing controversies and future directions in the field.
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Affiliation(s)
- William Spears
- Department of Neurology, Boston University, Boston Medical Center, 85 East Concord Street, Room 1145, Boston, MA, 02118, USA
| | - Asim Mian
- Department of Radiology, Boston University, Boston Medical Center, 820 Harrison Avenue FGH, 3rd floor, Boston, USA
| | - David Greer
- Department of Neurology, Boston University, Boston Medical Center, 85 East Concord Street, Room 1145, Boston, MA, 02118, USA.
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25
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Association of network connectivity via resting state functional MRI with consciousness, mortality, and outcomes in neonatal acute brain injury. Neuroimage Clin 2022; 34:102962. [PMID: 35152054 PMCID: PMC8851268 DOI: 10.1016/j.nicl.2022.102962] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 01/07/2023]
Abstract
Basal ganglia and seizure onset zone networks were associated with motor outcomes. Broad language/cognitive region networks were associated with developmental delay. Discharge with mortality was linked to default mode and language/cognitive networks. Exams were not linked to networks after multiple testing corrections. Lack of detection of all studied networks only occurred in those who did not survive.
Background An accurate and comprehensive test of integrated brain network function is needed for neonates during the acute brain injury period to inform on morbidity. This retrospective cohort study assessed whether integrated brain network function acquired by resting state functional MRI during the acute period in neonates with brain injury, is associated with acute exam, neonatal mortality, and 6-month outcomes. Methods Study subjects included 40 consecutive neonates with resting state functional MRI acquired within 31 days after suspected brain insult from March 2018 to July 2019 at Phoenix Children’s Hospital. Acute-period exam and test results were assigned ordinal scores based on severity as documented by respective treating specialists. Analyses (Fisher exact, Wilcoxon-rank sum test, ordinal/multinomial logistic regression) examined association of resting state networks with demographics, presentation, neurological exam, electroencephalogram, anatomical MRI, magnetic resonance spectroscopy, passive task functional MRI, and outcomes of discharge condition, outpatient development, motor tone, seizure, and mortality. Results Subjects had a mean (standard deviation) gestational age of 37.8 (2.6) weeks, a majority were male (63%), with a diagnosis of hypoxic ischemic encephalopathy (68%). Findings at birth included mild distress (48%), moderately abnormal neurological exam (33%), and consciousness characterized as awake but irritable (40%). Significant associations after multiple testing corrections were detected for resting state networks: basal ganglia with outpatient developmental delay (odds ratio [OR], 14.5; 99.4% confidence interval [CI], 2.00–105; P < .001) and motor tone/weakness (OR, 9.98; 99.4% CI, 1.72–57.9; P < .001); language/frontoparietal network with discharge condition (OR, 5.13; 99.4% CI, 1.22–21.5; P = .002) and outpatient developmental delay (OR, 4.77; 99.4% CI, 1.21–18.7; P=.002); default mode network with discharge condition (OR, 3.72; 99.4% CI, 1.01–13.78; P=.006) and neurological exam (P = .002 (FE); OR, 11.8; 99.4% CI, 0.73–191; P = .01 (OLR)); and seizure onset zone with motor tone/weakness (OR, 3.31; 99.4% CI, 1.08–10.1; P=.003). Resting state networks were not detected in three neonates, who died prior to discharge. Conclusions This study provides level 3 evidence (OCEBM Levels of Evidence Working Group) demonstrating that in neonatal acute brain injury, the degree of abnormality of resting state networks is associated with acute exam and outcomes. Total lack of brain network detection was only found in patients who did not survive.
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Bluhme E, Henckel E, Gramignoli R, Kjellin T, Hammarstedt C, Nowak G, Karadagi A, Johansson H, Jynge Ö, Söderström M, Fischler B, Strom S, Ellis E, Hallberg B, Jorns C. Procurement and Evaluation of Hepatocytes for Transplantation From Neonatal Donors After Circulatory Death. Cell Transplant 2022; 31:9636897211069900. [PMID: 35094608 PMCID: PMC8811420 DOI: 10.1177/09636897211069900] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Hepatocyte transplantation is a promising treatment for liver failure and inborn metabolic liver diseases, but progress has been hampered by a scarcity of available organs. Here, hepatocytes isolated from livers procured for a neonatal hepatocyte donation program within a research setting were assessed for metabolic function and suitability for transplantation. Organ donation was considered for infants who died in neonatal intensive care in the Stockholm region during 2015–2021. Inclusion was assessed when a decision to discontinue life-sustaining treatment had been made and hepatectomy performed after declaration of death. Hepatocyte isolation was performed by three-step collagenase perfusion. Hepatocyte viability, yield, and function were assessed using fresh and cryopreserved cells. Engraftment and maturation of cryopreserved neonatal hepatocytes were assessed by transplantation into an immunodeficient mouse model and analysis of the gene expression of phase I, phase II, and liver-specific enzymes and proteins. Twelve livers were procured. Median warm ischemia time (WIT) was 190 [interquartile range (IQR): 80–210] minutes. Median viability was 86% (IQR: 71%–91%). Median yield was 6.9 (IQR: 3.4–12.8) x106 viable hepatocytes/g. Transplantation into immunodeficient mice resulted in good engraftment and maturation of hepatocyte-specific proteins and enzymes. A neonatal organ donation program including preterm born infants was found to be feasible. Hepatocytes isolated from neonatal donors had good viability, function, and engraftment despite prolonged WIT. Therefore, neonatal livers should be considered as a donor source for clinical hepatocyte transplantation, even in cases with extended WIT.
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Affiliation(s)
- Emil Bluhme
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Ewa Henckel
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Roberto Gramignoli
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Therese Kjellin
- Department of Neonatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Christina Hammarstedt
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Greg Nowak
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Ahmad Karadagi
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Helene Johansson
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Öystein Jynge
- Organisation for Organ Donation in Central Sweden, Stockholm, Sweden
| | - Maria Söderström
- Organisation for Organ Donation in Central Sweden, Stockholm, Sweden
| | - Björn Fischler
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Stephen Strom
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Ewa Ellis
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Boubou Hallberg
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Carl Jorns
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Department of Transplantation, Karolinska University Hospital, Stockholm, Sweden
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Lemmon ME, Wusthoff CJ, Boss RD, Rasmussen LA. Ethical considerations in the care of encephalopathic neonates treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101258. [PMID: 34176763 PMCID: PMC8627487 DOI: 10.1016/j.siny.2021.101258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Engaging with ethical issues is central to the management of neonatal encephalopathy (NE). As treatment for these neonates evolves, new ethical issues will arise and many existing challenges will remain. We highlight three key ethical issues that arise in the care of neonates with NE treated with therapeutic hypothermia: facilitating shared decision making, understanding futility, and defining the boundaries between standard of care and research. Awareness of these issues will help clinicians counsel families in light of evolving treatments and outcomes.
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Affiliation(s)
- Monica E. Lemmon
- Division of Pediatric Neurology and Developmental Medicine, Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, DUMC 3936, Durham, NC, 27710, USA,Corresponding author. (M.E. Lemmon)
| | - Courtney J. Wusthoff
- Departments of Neurology and Pediatrics, Stanford University, Stanford, 750 Welch Road, Suite 317, Palo Alto, CA, 94304, USA
| | - Renee D. Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins Berman Institute of Bioethics, 200 N. Wolfe St, Suite 2019, Baltimore, MD, 21287, United States
| | - Lisa Anne Rasmussen
- Division of Palliative Care, Department of Family Medicine, Department of Neurology, Department of Pediatrics, Larner College of Medicine, University of Vermont, UVM Medical Center Palliative Care, 111 Colchester Avenue, Main Campus, Smith 262, Burlington, VT, 05401-1473, USA.
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28
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Fainberg N, Mataya L, Kirschen M, Morrison W. Pediatric brain death certification: a narrative review. Transl Pediatr 2021; 10:2738-2748. [PMID: 34765497 PMCID: PMC8578760 DOI: 10.21037/tp-20-350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/05/2021] [Indexed: 11/30/2022] Open
Abstract
In the five decades since its inception, brain death has become an accepted medical and legal concept throughout most of the world. There was initial reluctance to apply brain death criteria to children as they are believed more likely to regain neurologic function following injury. In spite of early trepidation, criteria for pediatric brain death certification were first proposed in 1987 by a multidisciplinary committee comprised of experts in the medical and legal communities. Protocols have since been developed to standardize brain death determination, but there remains substantial variability in practice throughout the world. In addition, brain death remains a topic of considerable ethical, philosophical, and legal controversy, and is often misrepresented in the media. In the present article, we discuss the history of brain death and the guidelines for its determination. We provide an overview of past and present challenges to its concept and diagnosis from biophilosophical, ethical and legal perspectives, and highlight differences between adult and pediatric brain death determination. We conclude by anticipating future directions for brain death as related to the emergence of new technologies. It is our position that providers should endorse the criteria for brain death diagnosis in children as proposed by the Society of Critical Care Medicine (SCCM), American Academy of Pediatrics (AAP), and Child Neurology Society (CNS), in order to prevent controversy and subjectivity surrounding what constitutes life versus death.
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Affiliation(s)
- Nina Fainberg
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leslie Mataya
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew Kirschen
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
| | - Wynne Morrison
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
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Abstract
PURPOSE OF REVIEW This article describes the prerequisites for brain death/death by neurologic criteria (BD/DNC), clinical evaluation for BD/DNC (including apnea testing), use of ancillary testing, and challenges associated with BD/DNC determination in adult and pediatric patients. RECENT FINDINGS Although death determination should be consistent among physicians and across hospitals, states, and countries to ensure that someone who is declared dead in one place would not be considered alive elsewhere, variability exists in the prerequisites, clinical evaluation, apnea testing, and use of ancillary testing to evaluate for BD/DNC. Confusion also exists about performance of an evaluation for BD/DNC in challenging clinical scenarios, such as for a patient who is on extracorporeal membrane oxygenation or a patient who was treated with therapeutic hypothermia. This prompted the creation of the World Brain Death Project, which published an international consensus statement on BD/DNC that has been endorsed by five world federations and 27 medical societies from across the globe. SUMMARY The World Brain Death Project consensus statement is intended to provide guidance for professional societies and countries to revise or develop their own protocols on BD/DNC, taking into consideration local laws, culture, and resource availability; however, it does not replace local medical standards. To that end, pending publication of an updated guideline on determination of BD/DNC across the lifespan, the currently accepted medical standards for BD/DNC in the United States are the 2010 American Academy of Neurology standard for determination of BD/DNC in adults and the 2011 Society of Critical Care Medicine/American Academy of Pediatrics/Child Neurology Society standard for determination of BD/DNC in infants and children.
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Mataya L, Ross LF, Ghavam A, Paquette ET. Pediatric Intensivist and Pediatric Neurologist Perspectives and Practices on Death by Neurologic Criteria. THE JOURNAL OF CLINICAL ETHICS 2021. [DOI: 10.1086/jce2021323195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Francoeur C, Weiss MJ, MacDonald JM, Press C, Greer DM, Berg RA, Topjian AA, Morrison W, Kirschen MP. Variability in Pediatric Brain Death Determination Protocols in the United States. Neurology 2021; 97:e310-e319. [PMID: 34050004 DOI: 10.1212/wnl.0000000000012225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/14/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To determine the variability in pediatric death by neurologic criteria (DNC) protocols between US pediatric institutions and compared to the 2011 DNC guidelines. METHODS In this cross-sectional study of DNC protocols obtained from pediatric institutions in the United States via regional organ procurement organizations, protocols were evaluated across 5 domains: general DNC procedures, prerequisites, neurologic examination, apnea testing, and ancillary testing. Descriptive statistics compared protocols to each other and the 2011 guidelines. RESULTS A total of 130 protocols were analyzed with 118 dated after publication of the 2011 guidelines. Of those 118 protocols, identification of a mechanism of irreversible brain injury was required in 97%, while 67% required an observation period after acute brain injury before DNC evaluation. Most protocols required guideline-based prerequisites such as exclusion of hypotension (94%), hypothermia (97%), and metabolic derangements (92%). On neurologic examination, 91% required a lack of responsiveness, 93% no response to noxious stimuli, and 99% loss of brainstem reflexes. A total of 84% of protocols required the guideline-recommended 2 apnea tests. CO2 targets were consistent with guidelines in 64%. Contrary to guidelines, 15% required ancillary testing for all patients and 15% permitted ancillary studies that are not validated in pediatrics. CONCLUSION Variability exists between pediatric institutional DNC protocols in all domains of DNC determination, especially with respect to apnea and ancillary testing. Better alignment of DNC protocols with national guidelines may improve the consistency and accuracy of DNC determination.
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Affiliation(s)
- Conall Francoeur
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Matthew J Weiss
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Jennifer M MacDonald
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Craig Press
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - David M Greer
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Robert A Berg
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Alexis A Topjian
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Wynne Morrison
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Matthew P Kirschen
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania.
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Noteworthy Professional News. Adv Neonatal Care 2021. [DOI: 10.1097/anc.0000000000000900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kirschen MP, McGowan N, Topjian A. Brain Death Evaluation in Children With Suspected or Confirmed Coronavirus Disease 2019. Pediatr Crit Care Med 2021; 22:318-322. [PMID: 33273410 PMCID: PMC7924933 DOI: 10.1097/pcc.0000000000002650] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVES To discuss the challenges of conducting a death by neurologic criteria or brain death evaluation in the coronavirus disease 2019 era and provide guidance to mitigate viral transmission risk and maintain patient safety during testing. DESIGN Not applicable. SETTING Not applicable. PATIENTS Children with suspected or confirmed coronavirus disease 2019 who suffer catastrophic brain injury due to one of numerous neurologic complications or from an unrelated process and require evaluation for death by neurologic criteria. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS There is a risk to healthcare providers from aerosol generation during the neurologic examination and apnea test for determination of death by neurologic criteria. In this technical note, we provide guidance to mitigate transmission risk and maintain patient safety during each step of the death by neurologic criteria evaluation. Clinicians should put on appropriate personal protective equipment before performing the death by neurologic criteria evaluation. Risk of aerosol generation and viral transmission during the apnea test can be mitigated by using continuous positive airway pressure delivered via the ventilator as a means of apneic oxygenation. Physicians should assess the risk of transporting coronavirus disease 2019 patients to the nuclear medicine suite to perform a radionucleotide cerebral blood flow study, as disconnections to and from the ventilator for transport and inadvertent ventilator disconnections during transport can increase transmission risk. CONCLUSIONS When conducting the neurologic examination and apnea test required for death by neurologic criteria determination in patients with suspected or confirmed coronavirus disease 2019, appropriate modifications are needed to mitigate the risk of viral transmission and ensure patient safety.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Neurology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nancy McGowan
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Kirschen MP, Lewis A, Rubin M, Kurtz P, Greer DM. New perspectives on brain death. J Neurol Neurosurg Psychiatry 2021; 92:255-262. [PMID: 33219040 DOI: 10.1136/jnnp-2020-323952] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/06/2020] [Accepted: 10/14/2020] [Indexed: 11/04/2022]
Abstract
Brain death, or death by neurological criteria (BD/DNC), has been accepted conceptually, medically and legally for decades. Nevertheless, some areas remain controversial or understudied, pointing to a need for focused research to advance the field. Multiple recent contributions have increased our understanding of BD/DNC, solidified our practice and provided guidance where previously lacking. There have also been important developments on a global scale, including in low-to-middle income countries such as in South America. Although variability in protocols and practice still exists, new efforts are underway to reduce inconsistencies and better train practitioners in accurate and sound BD/DNC determination. Various legal challenges have required formal responses from national societies, and the American Academy of Neurology has filled this void with much needed guidance. Questions remain regarding concepts such as 'whole brain' versus 'brainstem' death, and the intersection of BD/DNC and rubrics of medical futility. These concepts are the subject of this review.
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Affiliation(s)
- Matthew P Kirschen
- Anesthesia and Critical Care Medicine, Neurology and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ariane Lewis
- Neurology and Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Michael Rubin
- Neurology, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Pedro Kurtz
- Hospital Copa Star, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - David M Greer
- Neurology, Boston University, Boston, Massachusetts, USA
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Hypothalamic function in patients diagnosed as brain dead and its practical consequences. HANDBOOK OF CLINICAL NEUROLOGY 2021; 182:433-446. [PMID: 34266610 DOI: 10.1016/b978-0-12-819973-2.00029-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Some patients who have been diagnosed as "dead by neurologic criteria" continue to exhibit certain brain functions, most commonly, neuroendocrine functions. In this chapter, we review the pathophysiology of brain death that can lead either to neuroendocrine failure or to preserved neuroendocrine functioning. We review the evidence on continued hypothalamic functioning in patients who have been declared "brain dead," examine potential mechanisms that would explain these findings, and discuss how these findings create additional confounds for brain death testing. We conclude by reviewing the evidence for the management of hypothalamic-pituitary failure in the setting of brain death and organ transplantation.
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Mayne E, Hong SJ. Ancillary Tests for Death by Neurologic Criteria in Children. Pediatr Neurol Briefs 2020; 34:26. [PMID: 33376295 PMCID: PMC7759328 DOI: 10.15844/pedneurbriefs-34-26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Investigators from Children's Hospital of Pennsylvania reported on the usage of ancillary studies in the declaration of brain death in children in a single-center retrospective descriptive study.
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Affiliation(s)
- Elizabeth Mayne
- Divisions of Neurology and Critical Care Medicine, Anne and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Sue J Hong
- Divisions of Neurology and Critical Care Medicine, Anne and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Apnea Testing in the Setting of Pediatric Brain Death: Continuous Positive Airway Pressure May Be the Safer Option. Pediatr Crit Care Med 2020; 21:1107-1108. [PMID: 33278226 DOI: 10.1097/pcc.0000000000002528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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A review of current controversies in determining death by neurologic criteria in children. Curr Opin Pediatr 2020; 32:759-764. [PMID: 33009123 DOI: 10.1097/mop.0000000000000952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Death by neurologic criteria (DNC) is the irreversible cessation of all functions of the entire brain, including the brainstem. It is legally recognized as equivalent to cardiopulmonary death. Legal and ethical controversies surrounding DNC have emerged as a result of several highly publicized cases that have eroded public trust in our ability to declare DNC accurately. In this review, we focus on recently published primary data about DNC and address some of these controversies. RECENT FINDINGS Approximately 21% of children who die in pediatric intensive care units (PICU) are declared DNC. Although 60% of physicians report that they have been asked to maintain organ support after DNC declaration, less than 1% of patients remain physically present in the PICU more than 5 days after DNC declaration. We discuss strategies for safely conducting the apnea test, indications and prevalence of ancillary testing, and objections to DNC, including issues of consent and requests for ongoing organ support. SUMMARY In order to maintain public trust, published guidelines must be followed to accurately and consistently diagnose DNC. We must develop strategies to respond to objections to DNC determination. Ongoing research is needed to improve the safety of apnea testing and indications for and interpretation of ancillary testing.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe ethical and legal issues that arise in the management of patients with disorders of consciousness ranging from the minimally conscious state to the coma state, as well as brain death. RECENT FINDINGS The recent literature highlights dilemmas created by diagnostic and prognostic uncertainties in patients with disorders of consciousness. The discussion also reveals the challenges experienced by the disability community, which includes individuals with severe brain injury who are classified as having a disorder of consciousness. We review current guidelines for management of patients with disorders of consciousness including discussions around diagnosis, prognosis, consideration of neuropalliation, and decisions around life sustaining medical treatment. SUMMARY In the setting of uncertainty, this review describes the utility of applying a disability rights perspective and shared decision-making process to approach medical decision-making for patients with disorders of consciousness. We outline approaches to identifying surrogate decision makers, standards for decision-making and decision-making processes, specifically addressing the concept of futility as a less useful framework for making decisions. We also highlight special considerations for research, innovative and controversial care, brain death, organ donation, and child abuse and neglect.
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Affiliation(s)
- Lauren Rissman
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Erin Talati Paquette
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Northwestern University Feinberg School of Medicine, Chicago, IL
- Northwestern University Pritzker School of Law (by courtesy), Chicago, IL
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Apnea Testing Using Continuous Positive Airway Pressure When Determining Death by Neurologic Criteria in Children: Retrospective Analysis of Potential Adverse Events. Pediatr Crit Care Med 2020; 21:e1152-e1156. [PMID: 32701745 DOI: 10.1097/pcc.0000000000002457] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the prevalence of adverse events during apnea testing for determination of death by neurologic criteria using continuous positive airway pressure in children. DESIGN Single-center retrospective descriptive study. SETTING Academic children's hospital. PATIENTS Children evaluated for death by neurologic criteria in the PICU from 2013 to 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For each patient evaluated for death by neurologic criteria, we abstracted the number of apnea tests performed, vital signs and arterial blood gases during apnea testing, and outcome from the medical record. Adverse events were defined as oxygen-hemoglobin desaturation (arterial oxygen saturation < 85%), hypotension, or other significant event (e.g. arrhythmia, cardiac arrest) based on documentation in the medical record. We determined which adverse events resulted in early termination of the apnea test. We used oxygenation index, ventilator variables, and presence of vasopressors to determine preapnea test cardiopulmonary dysfunction. Seventy-two patients (age 7 yr [2.7-13.2 yr]; 48% male) underwent 121 apnea tests. Nine patients (12%) had 13 potential apnea tests deferred due to concern for cardiopulmonary instability as determined by the attending physician. Patients who underwent apnea testing had an oxygenation index of 3.5 (2.5-4.8) and were receiving vasopressors at the time of 108 apnea tests (89%). Hypotension was reported during seven apnea tests (6%) and resulted in the early termination of one apnea test (<1%). No other adverse events were reported. One hundred and twenty apnea tests (99%) were consistent with death by neurologic criteria. CONCLUSIONS Apnea testing following a protocol that uses continuous positive airway pressure for apneic oxygenation has a low rate of adverse events in children meeting prerequisite criteria and determined by a pediatric intensivist to be physiologically appropriate for testing.
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Abstract
OBJECTIVE The purpose of this study is to determine the potential role of dynamic susceptibility contrast (DSC) magnetic resonance (MR) perfusion imaging in diagnosing brain death. MATERIALS AND METHODS The study population was composed of 61 subjects (the Glasgow Coma Scale [GCS] score was 3 for all subjects), and 26 subjects were assigned to the control group (GCS scores between 4 and 6). At least four regions of interest (ROIs) from different anatomical regions were measured, the mean transit time (MTT), cerebral blood flow (CBF), and signal intensity time-to-course graphic were calculated. A second neurological examination (including an apnea test) was accepted as the gold standard method for the diagnosis of brain death. RESULTS DSC-MR perfusion imaging diagnosed brain death with a specificity of 100% (61/61) and a sensitivity of 86.8% (53/61). A cut-off value of maximum 3.5% decrease in the signal intensity time-to-course graphic was calculated by the Youden's index and established for the to differentiate brain death from other conditions. CONCLUSION DSC-MR perfusion imaging is a promising tool that may be used as a reliable add-on confirmatory diagnostic test for the brain death.
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Greer DM, Shemie SD, Lewis A, Torrance S, Varelas P, Goldenberg FD, Bernat JL, Souter M, Topcuoglu MA, Alexandrov AW, Baldisseri M, Bleck T, Citerio G, Dawson R, Hoppe A, Jacobe S, Manara A, Nakagawa TA, Pope TM, Silvester W, Thomson D, Al Rahma H, Badenes R, Baker AJ, Cerny V, Chang C, Chang TR, Gnedovskaya E, Han MK, Honeybul S, Jimenez E, Kuroda Y, Liu G, Mallick UK, Marquevich V, Mejia-Mantilla J, Piradov M, Quayyum S, Shrestha GS, Su YY, Timmons SD, Teitelbaum J, Videtta W, Zirpe K, Sung G. Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project. JAMA 2020; 324:1078-1097. [PMID: 32761206 DOI: 10.1001/jama.2020.11586] [Citation(s) in RCA: 262] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. OBJECTIVE To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. PROCESS Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. EVIDENCE SYNTHESIS Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. RECOMMENDATIONS Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability. CONCLUSIONS AND RELEVANCE This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.
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Affiliation(s)
- David M Greer
- Boston University School of Medicine, Boston, Massachusetts
| | - Sam D Shemie
- McGill University, Montreal Children's Hospital, Montreal, Canada
- Canadian Blood Services, Ottawa, Canada
| | | | | | | | | | - James L Bernat
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | | | - Anne W Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis
| | - Marie Baldisseri
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas Bleck
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Arnold Hoppe
- Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Stephen Jacobe
- University of Sydney and Children's Hospital of Westmead, Westmead, Australia
| | | | | | | | | | | | | | - Rafael Badenes
- Hospital Clinic Universitari, University of Valencia, Valencia, Spain
| | - Andrew J Baker
- St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Canada
| | - Vladimir Cerny
- J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic
| | | | - Tiffany R Chang
- The University of Texas Health Science Center at Houston, Houston
| | | | - Moon-Ku Han
- Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | | | | | | | - Gang Liu
- Capital Medical University, Beijing, China
| | | | | | | | | | | | | | | | | | | | - Walter Videtta
- National Hospital, Alejandro Posadas, Buenos Aires, Argentina
| | | | - Gene Sung
- University of Southern California, Los Angeles
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Krawiec C, Ceneviva GD, Zhou S, Thomas N. Evaluating the Utility of Toxicologic Analysis in Pediatric Out-of-Hospital Cardiac Arrest. J Emerg Med 2020; 59:e167-e174. [PMID: 32917447 DOI: 10.1016/j.jemermed.2020.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/12/2020] [Accepted: 07/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The cause of a pediatric out-of-hospital cardiac arrest (OHCA) may go unexplained in the emergency department setting but can be secondary to a toxicologic etiology. It is unclear how toxicologic screens are used in the postarrest period after a pediatric OHCA. OBJECTIVES The primary objectives are to describe 1) when the toxicology screen (urine and serum) is used, 2) patient characteristics, and 3) toxicology screen results. We hypothesized that toxicology screens are frequently used but that positive results are uncommon. METHODS This was a retrospective study of pediatric OHCA patients admitted to the Penn State Health Children's Hospital pediatric intensive care unit as transfers from the emergency department between January 1, 2011 and May 31, 2018. We reviewed the electronic health record and evaluated for toxicology screen completion, patient characteristics, and toxicology screen results. RESULTS One hundred forty-one patients had a pediatric OHCA. Sixty-three (44.7%) patients did not have a toxicology screen completed. A toxicology screen had a higher completion rate for children >11 years of age (n = 26 [78.8%]; p = 0.0024), and in unwitnessed arrests (n = 48 [66.7%]; p = 0.0052). Four cases (5.1%) revealed the presence of substances that were not administered by a medical provider or were illicit. CONCLUSION Our study found that in pediatric OHCA, toxicologic screens were completed but were not routinely sent in our institution. There may be factors such as clinician bias or the severity of a patient's illness that impact the approach to toxicologic screening in pediatric OHCA. In addition to the history and physical examination, emergency physician and pediatric intensivists should consider routinely sending toxicologic screens to assist in uncovering any accidental or malicious explanation for the event.
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Affiliation(s)
- Conrad Krawiec
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Gary Dominic Ceneviva
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Shouhao Zhou
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Neal Thomas
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
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Ettinger NA, Coleman RD, Loftis LL. Pediatric Intensivists Reply to "Can a Parent Refuse the Brain Death Examination?". Pediatrics 2020; 146:peds.2020-008144B. [PMID: 32868468 DOI: 10.1542/peds.2020-008144b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Nicholas A Ettinger
- Assistant Professor, Pediatric Critical Care, Baylor College of Medicine/Texas Children's Hospital
| | - Ryan D Coleman
- Assistant Professor, Pediatric Critical Care, Baylor College of Medicine/Texas Children's Hospital; BCM Center for Medical Ethics and Health Policy
| | - Laura L Loftis
- Associate Professor, Pediatric Critical Care, Baylor College of Medicine/Texas Children's Hospital; BCM Center for Medical Ethics and Health Policy
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Abstract
Despite being an international reference in donation and transplantation, Spain needs to improve pediatric donation, including donation after the circulatory determination of death. The present article, a summary of the consensus report prepared by the Organización Nacional de Trasplantes and the Spanish Pediatrics Association, intends the facilitation of donation procedures in newborns and children and the analysis of associated ethical dilemma. The ethical basis for donation in children, the principles of clinical assessment of possible donors, the criteria for the determination of death in children, intensive care management of donors, basic concepts of donation after the circulatory determination of death and the procedures for donation in newborns with severe nervous system's malformation incompatible with life, as well as in children receiving palliative care are commented. Systematically considering the donation of organs and tissues when a child dies in conditions consistent with donation is an ethical imperative and must become an ethical standard, not only because of the need of organs for transplantation, but also to ensure family centered care.
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46
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Nair-Collins M, Miller FG. Current Practice Diagnosing Brain Death Is Not Consistent With Legal Statutes Requiring the Absence of All Brain Function. J Intensive Care Med 2020; 37:153-156. [DOI: 10.1177/0885066620939037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The legal standard for the determination of death by neurologic criteria in the United States is laid out in the Uniform Determination of Death Act (UDDA), which requires the irreversible cessation of all functions of the entire brain. Most other nations endorse a “whole-brain” standard as well. However, current practice in the determination of death by neurologic criteria is not consistent with this legal standard, because some patients who are diagnosed as brain-dead, in fact retain some brain function, or retain the capacity for the return of some brain function. In response, the American Academy of Neurology published updated guidelines, which assert that hypothalamic function is consistent with the neurological standard enshrined in the UDDA. Others have suggested that it is an open question whether the hypothalamus and pituitary are part of “the entire brain,” as delineated in the UDDA. While we agree that determination of death practices are worthy of continued dialogue and refinement in practice that dialogue must adhere to reasonable standards of logic and scientific accuracy.
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Affiliation(s)
- Michael Nair-Collins
- Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Franklin G. Miller
- Medical Ethics in Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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47
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Rodríguez Núñez A, Pérez Blanco A. [National recommendations on pediatric donation]. An Pediatr (Barc) 2020; 93:134.e1-134.e9. [PMID: 32620317 PMCID: PMC7326462 DOI: 10.1016/j.anpedi.2020.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 11/07/2022] Open
Abstract
A pesar de ser una referencia internacional en donación y trasplante, España precisa mejorar los procesos de donación en niños, en particular la donación tras la determinación de la muerte por criterios circulatorios (donación en asistolia). El presente artículo, resumen del documento de consenso elaborado por la Organización Nacional de Trasplantes y la Asociación Española de Pediatría, pretende facilitar los procesos de donación en niños y neonatos y analizar los conflictos éticos que plantea. Se comentan los fundamentos éticos de la donación pediátrica, los principios de la evaluación clínica de los posibles donantes, los criterios diagnósticos de muerte encefálica en niños, los cuidados intensivos para el mantenimiento de los donantes, los conceptos básicos de la donación en asistolia y los procesos de donación en neonatos con malformaciones muy graves del sistema nervioso incompatibles con la vida y en niños en cuidados paliativos. Considerar sistemáticamente la donación de órganos y tejidos cuando un niño fallece en condiciones de ser donante es un imperativo ético y ha de constituir un estándar profesional, tanto por la necesidad de órganos para trasplante, como por asegurar un cuidado integral centrado en la familia.
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Affiliation(s)
- Antonio Rodríguez Núñez
- Sección de Pediatría Crítica, Cuidados Intermedios y Paliativos Pediátricos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España.
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48
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Lyons C, Callaghan M. Apnoeic oxygenation in paediatric anaesthesia: a narrative review. Anaesthesia 2020; 76:118-127. [PMID: 32592510 DOI: 10.1111/anae.15107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2020] [Indexed: 12/19/2022]
Abstract
Apnoeic oxygenation refers to oxygenation in the absence of any patient or ventilator effort to move the lungs. This phenomenon was first described in humans in the mid-20th century but has seen renewed interest in the last decade following the demonstration of apnoeic oxygenation with low-flow, and subsequently high-flow, nasal oxygen. This narrative review summarises our understanding of apnoeic oxygenation in the paediatric population. We examine the evidence supporting oxygenation via tracheal tube, modified laryngoscopes and nasal cannulae. The evidence for prolongation of safe apnoea time at induction of anaesthesia is also appraised. We explore the capacity for carbon dioxide clearance, flow rate selection with high-flow nasal oxygen and complications associated with the technique. It remains uncertain whether apnoeic oxygenation in paediatric patients results in a meaningful clinical benefit compared with standard care for outcomes such as the number of tracheal intubation attempts or the incidence of hypoxaemia. In particular, the role of apnoeic oxygenation in paediatric difficult airway management is unclear as this has not been the targeted focus of any published research to date.
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Affiliation(s)
- C Lyons
- Department of Anaesthesia, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - M Callaghan
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
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49
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Berkowitz I, Garrett JR. Legal and Ethical Considerations for Requiring Consent for Apnea Testing in Brain Death Determination. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:4-16. [PMID: 32441596 DOI: 10.1080/15265161.2020.1754501] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The past decade has witnessed escalating legal and ethical challenges to the diagnosis of death by neurologic criteria (DNC). The legal tactic of demanding consent for the apnea test, if successful, can halt the DNC. However, US law is currently unsettled and inconsistent in this matter. Consent has been required in several trial cases in Montana and Kansas but not in Virginia and Nevada. In this paper, we analyze and evaluate the legal and ethical bases for requiring consent before apnea testing and defend such a requirement by appealing to ethical and legal principles of informed consent and battery and the right to refuse medical treatment. We conclude by considering and rebutting two major objections to a consent requirement for apnea testing: (1) a justice-based objection to allocate scarce resources fairly and (2) a social utility objection that halting the diagnosis of brain death will reduce the number of organ donors.
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50
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Determination of Death by Neurologic Criteria: Paco2 and the Three Phases of the Apnea Test. Pediatr Crit Care Med 2020; 21:497-498. [PMID: 32358331 DOI: 10.1097/pcc.0000000000002227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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