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McKinnon NK, Maratta C, Zuckier LS, Boyd JG, Chassé M, Hornby L, Kramer A, Kromm J, Mooney OT, Muthusami P, Nitulescu R, Park J, Slessarev M, Basmaji J. Ancillary investigations for death determination in infants and children: a systematic review and meta-analysis. Can J Anaesth 2023; 70:749-770. [PMID: 37131035 PMCID: PMC10203011 DOI: 10.1007/s12630-023-02418-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 05/04/2023] Open
Abstract
PURPOSE We performed a systematic review and meta-analysis to determine the diagnostic test accuracy of ancillary investigations for declaration of death by neurologic criteria (DNC) in infants and children. SOURCE We searched MEDLINE, EMBASE, Web of Science, and Cochrane databases from their inception to June 2021 for relevant randomized controlled trials, observational studies, and abstracts published in the last three years. We identified relevant studies using Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology and a two-stage review. We assessed the risk of bias using the QUADAS-2 tool, and applied Grading of Recommendations Assessment, Development, and Evaluation methodology to determine the certainty of evidence. A fixed-effects model was used to meta-analyze pooled sensitivity and specificity data for each ancillary investigation with at least two studies. PRINCIPAL FINDINGS Thirty-nine eligible manuscripts assessing 18 unique ancillary investigations (n = 866) were identified. The sensitivity and specificity ranged from 0.00 to 1.00 and 0.50 to 1.00, respectively. The quality of evidence was low to very low for all ancillary investigations, with the exception of radionuclide dynamic flow studies for which it was graded as moderate. Radionuclide scintigraphy using the lipophilic radiopharmaceutical 99mTc-hexamethylpropyleneamine oxime (HMPAO) with or without tomographic imaging were the most accurate ancillary investigations with a combined sensitivity of 0.99 (95% highest density interval [HDI], 0.89 to 1.00) and specificity of 0.97 (95% HDI, 0.65 to 1.00). CONCLUSION The ancillary investigation for DNC in infants and children with the greatest accuracy appears to be radionuclide scintigraphy using HMPAO with or without tomographic imaging; however, the certainty of the evidence is low. Nonimaging modalities performed at the bedside require further investigation. STUDY REGISTRATION PROSPERO (CRD42021278788); registered 16 October 2021.
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Affiliation(s)
- Nicole K McKinnon
- Department of Critical Care, The Hospital for Sick Children (SickKids), 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Neuroscience and Mental Health, Peter Gilgan Centre for Research and Learning, Toronto, ON, Canada.
| | - Christina Maratta
- Department of Critical Care, The Hospital for Sick Children (SickKids), 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lionel S Zuckier
- Division of Nuclear Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Departments of Medicine and Radiology, University of Ottawa, Ottawa, ON, Canada
| | - J Gordon Boyd
- Departments of Medicine (Neurology) and Critical Care Medicine, Kingston General Hospital, Kingston, ON, Canada
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Michaël Chassé
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Centre de Recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montreal, QC, Canada
| | | | - Andreas Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Julie Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Alberta Health Services, Calgary, AB, Canada
| | - Owen T Mooney
- Section of Critical Care, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Prakash Muthusami
- Department of Diagnostic Imaging, Hospital for Sick Children (SickKids), Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Roy Nitulescu
- Centre de Recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montreal, QC, Canada
| | - Jaewoo Park
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marat Slessarev
- Department of Medicine, Western University, London, ON, Canada
| | - John Basmaji
- Department of Medicine, Western University, London, ON, Canada
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Abstract
A 2-year-old boy with severe head trauma was diagnosed brain dead according to the 2011 Pediatric Guidelines. Computed tomographic (CT) scan showed massive cerebral edema with herniation. Intracranial pressures were extremely high, with cerebral perfusion pressures around 0 for several hours. An apnea test was initially contraindicated; later, one had to be terminated due to oxygen desaturation when the Pco2 had risen to 57.9 mm Hg. An electroencephalogram (EEG) was probably isoelectric but formally interpreted as equivocal. Tc-99m diethylene-triamine-pentaacetate (DTPA) scintigraphy showed no intracranial blood flow, so brain death was declared. Parents declined organ donation. A few minutes after withdrawal of support, the boy began to breathe spontaneously, so the ventilator was immediately reconnected and the death declaration rescinded. Two hours later, life support was again removed, this time for prognostic reasons; he did not breathe, and death was declared on circulatory-respiratory grounds. Implications regarding the specificity of the guidelines are discussed.
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Affiliation(s)
- D Alan Shewmon
- 1 David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Nakagawa TA, Ashwal S, Mathur M, Mysore M. Clinical report—Guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations. Pediatrics 2011; 128:e720-40. [PMID: 21873704 DOI: 10.1542/peds.2011-1511] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To review and revise the 1987 pediatric brain death guidelines. METHODS Relevant literature was reviewed. Recommendations were developed using the GRADE system. CONCLUSIONS AND RECOMMENDATIONS (1) Determination of brain death in term newborns, infants and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma. Because of insufficient data in the literature, recommendations for preterm infants less than 37 weeks gestational age are not included in this guideline. (2) Hypotension, hypothermia, and metabolic disturbances should be treated and corrected and medications that can interfere with the neurologic examination and apnea testing should be discontinued allowing for adequate clearance before proceeding with these evaluations. (3) Two examinations including apnea testing with each examination separated by an observation period are required. Examinations should be performed by different attending physicians. Apnea testing may be performed by the same physician. An observation period of 24 hours for term newborns (37 weeks gestational age) to 30 days of age, and 12 hours for infants and chi (> 30 days to 18 years) is recommended. The first examination determines the child has met the accepted neurologic examination criteria for brain death. The second examination confirms brain death based on an unchanged and irreversible condition. Assessment of neurologic function following cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for 24 hours or longer if there are concerns or inconsistencies in the examination. (4) Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial Paco(2) 20 mm Hg above the baseline and ≥ 60 mm Hg with no respiratory effort during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed. (5) Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. Ancillary studies may be us d to assist the clinician in making the diagnosis of brain death (i) when components of the examination or apnea testing cannot be completed safely due to the underlying medical condition of the patient; (ii) if there is uncertainty about the results of the neurologic examination; (iii) if a medication effect may be present; or (iv) to reduce the inter-examination observation period. When ancillary studies are used, a second clinical examination and apnea test should be performed and components that can be completed must remain consistent with brain death. In this instance the observation interval may be shortened and the second neurologic examination and apnea test (or all components that are able to be completed safely) can be performed at any time thereafter. (6) Death is declared when the above criteria are fulfilled.
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Nakagawa TA, Ashwal S, Mathur M, Mysore MR, Bruce D, Conway EE, Duthie SE, Hamrick S, Harrison R, Kline AM, Lebovitz DJ, Madden MA, Montgomery VL, Perlman JM, Rollins N, Shemie SD, Vohra A, Williams-phillips JA. Guidelines for the determination of brain death in infants and children: An update of the 1987 Task Force recommendations*: . Crit Care Med 2011; 39:2139-55. [DOI: 10.1097/ccm.0b013e31821f0d4f] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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