Journal of Pediatric Critical Care

P - ISSN : 2349-6592    |    E - ISSN : 2455-7099

Guidelines
Year : 2014 | Volume : 1 | Issue : 4 | Page : 302-305

Pediatric Brain Death Guidelines

Pediatric Braindeath Guidelines Group 2011

Correspondence Address:

Dr. Bala Ramachandran
PICU, Kanchi Kamakoti CHILDS Trust Hospital
12A Nageswara Road, Nungambakkam, Chennai - 600 034
email:mdpicu@hotmail.com

Received:14-Jul-2014/Accepted:24-Oct-2014 /Published online:15-Nov-2014

Source of Funding:None Conflict of Interest:None


Introduction
The diagnosis of Brain Death in children is generally regarded as being more dificult than in adults and there is considerable variation in the exact protocol followed in different countries, and even between different states in the same country. Nevertheless, the diagnostic procedure is essentially by clinical examination.

The following guidelines are based on multiple sources, including the American Academy of Pediatrics Guidelines for the determination of brain death in children1,4, the American Academy of Neurology evidence based guideline update 20102, the Australian and New Zealand Intensive Care Society statement on death and organ donation, 20083 and the general consensus of the Guidelines committee of experts from India listed at the end of this article (Guidelines group was chaired and coordinated by Dr Balaramachandran in year 2011 and this consensus was compiled by him on behalf of the Guidelines group).

Definition
Brain death is defined as irreversible cessation of all functions of the entire brain, including the brain stem

Pre-requisites
The following conditions must be met before brain death can be determined:
1. There must be a recognized cause of coma suficient to explain the irreversible cessation of all brain function. Both coma and apnea must coexist to declare brain death.
2. Potentially reversible causes of coma must be excluded
a. Hypothermia –– core body temperature must be > 35o C, since severely hypothermic patients may appear brain dead
b. Uncontrolled hypotension –– the blood pressure must be normal for age (systolic BP not < 2 SD below norm for age)
c. Sedatives and other CNS depressant drugs / toxins –– sufficient time must be allowed for any CNS depressant agents to be metabolized. If this cannot be assured, a drug level may be obtained, if possible, to show that the drug in question does not exceed the normal therapeutic levels.
d. If neuromuscular blocking agents have been administered, a peripheral nerve stimulator should be used to show that there is no residual neuromuscular blockade
e. Severe metabolic derangements must be excluded, including markedly abnormal plasma concentrations of glucose, sodium, potassium, phosphate, magnesium, calcium
f. Any other sign that suggests a potentially reversible cause of coma
3. Neurological assessment may be unreliable immediately following cardiopulmonary resuscitation or acute brain injury –– brain death evaluation should be deferred by 24 hours in these circumstances.

Clinical Examination
The diagnosis of brain death is essentially clinical.
There must be absence of higher brain function –– lack of consciousness
There must be absence of brain stem functions

NOTE
Observations that are compatible with brain death
•• The following observations can be present in brain death
•• Spinal reflexes in response to stimulation •
•• These may include movements of the upper limbs, deep tendon reflexes, plantar reflexes, respiratory like movements and head turning
••• Sweating, blushing or tachycardia
••• Normal blood pressure without pharmacological support
••• Absence of diabetes insipidus

Observations that are incompatible with brain death

The following observations are incompatible with brain death: •
• Decerebrate or decorticate posturing •
• True extensor or flexor responses to painful stimuli
•• Seizures

Number of tests and who should perform them
Two examinations (including two apnea tests) should be performed, separated by an interval. A different Consultant Physician who is taking care of the child should perform each clinical examination. These physicians should have specific expertise and experience in performing such assessment and can include Pediatric Intensivists, Neurologists, Anesthetists, Neurosurgeons or Pediatricians. The same individual may perform the apnea tests. In case the testing is being performed for the purposes of organ harvesting, additional requirements from the individual State Governments may apply (such as pre-registration and authorization of the physician performing the tests).

Demonstration of apnea
The role of the apnea test has been questioned recently5. Nevertheless, it continues to be a part of the Brain Death testing protocol in most countries at this time. The apnea test must be performed twice (as part of each clinical exam), but may be performed by the same individual –– preferably the physician who is managing the patient’’s ventilator. The following section describes how to perform the apnea test.

The same pre-requisites apply as for performing the clinical tests –– i.e. the patient should not be hypothermic, hypotensive or have a serious metabolic or endocrine disturbance. Additional contraindications include a high cervical spinal cord injury or very high oxygen / ventilatory requirements that will result in the inability to disconnect safely from the ventilator. If the apnea tests cannot be performed safely, then an ancillary test must be performed to determine brain death.

1. Pre-oxygenate the patient for 5 minutes with 100% oxygen.
2. The physician involved in certifying brain death should be physically present at the bedside during the test to attest to the presence of apnea.
3. Manipulate the ventilator to allow the PaCO2 to rise to > 40 mm Hg –– this baseline arterial CO2 should be confirmed by blood gas analysis or end tidal CO2
4. Monitor the patient during the test (ECG, blood pressure and SpO2) and stop the test if there is significant hypotension, desaturation or cardiac arrhythmia
5. Disconnect the patient from the mechanical ventilator and insert an appropriately sized oxygen catheter into the endotracheal tube. Adjust the oxygen flow to deliver 100% oxygen at a flow rate between 2 –– 6 L/min. Use only the minimum flow required to maintain adequate oxygen saturation. A T-piece or CPAP circuit can also be used to supply oxygen to the patient when disconnected from the ventilator.
6. After a period of apnea of between 5 –– 10 minutes (depending on the PaCO2 at the beginning of the test), perform an arterial blood gas. The PaCO2 on the ABG should be >= 60 mm Hg and >= 20 mm Hg more than the baseline level. If the PaCO2 does not meet these parameters, the test may be continued and the ABG repeated after 5 minutes, provided the patient continues to be stable.
7. Observe the patient continuously for the presence of any respiratory efforts. If any respiratory efforts are noted, abandon the test immediately. If there is complete apnea, note the duration of apnea and the PaCO2 at the end of the test.
8. Reconnect the patient to the mechanical ventilator.

Response:In a brain dead patient, no respiratory efforts should be seen during the period of apnea.

Ancillary Tests
Ancillary tests are not routinely required to determine brain death and are not a substitute for the clinical examination. However, they may be used in specific situations:
a. When the apnea test cannot be performed safely
b. If there is uncertainty regarding the results of the neurological examination
c. If a medication may be present that would preclude declaration of brain death
d. In order to reduce the waiting period between the two sets of tests A number of ancillary tests are available.

EEG
A digital EEG should be performed by a technician who has experience in performing EEG’’s for the purposes of determining brain death. In general, the sensitivity should be increased to 2 µV, the high frequency filter should be set above 30 Hz and the low frequency filter set not above 1 Hz. A minimum of eight scalp electrodes should be used. The EEG should demonstrate a lack of reactivity to intense somatosensory and audiovisual stimulation.

Tests to Assess Intracranial Blood Flow
The purpose of these tests is to show that there is no flow in the intracerebral vessels, due to occlusion of the vasculature by cerebral edema. The various techniques by which intracranial blood flow can be assessed include four vessel cerebral angiography, Radionuclide imaging, CT angiography, Magnetic Resonance angiography and Trans Cranial Doppler ultrasonography. Of these techniques, four-vessel cerebral angiography is regarded as the gold standard and involves direct injection of contrast medium into both Carotid arteries and both Vertebral arteries. Of all the confirmatory tests mentioned above, EEG is the most easily available test. Radionuclide cerebral blood flow assessment is also acceptable –– the remainder are time consuming, not easily available, not always standardized, may require shifting an unstable patient and, in some cases, expensive. Any one of the following tests may be used (depending on availability) when an ancillary test is required:
i. EEG
ii. Radionuclide cerebral blood flow assessment
iii. Four vessel cerebral angiography.

Time Course of Tests for Brain Death
•• The clinical tests are performed twice, each time by a different physician •
• The apnea test is performed twice –– may be performed by the same physician
•• Death is declared when the second neurological examination and apnea test confirm that the results of the first tests are unchanged and the changes are irreversible
•• If an ancillary test performed after the first clinical examination/apnea test is consistent with brain death, then the second clinical examination / apnea test can be performed at any time



References
1. American Academy of Pediatrics, Task Force on Brain Death in Children. Report of Special Task Force: guidelines for determination of brain death in children. Pediatrics. 1987; 80(2): 298-300
2. Eelco F.M. Wijdicks, Panayiotis N. Varelas, Gary S. Gronseth, et al. Evidence-based guideline update: Determining brain death in adults : Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010;74;1911
3. Australian and New Zealand Intensive Care Society. The ANZICS Statement on Death and Organ Donation (3rd Edition). Melbourne: ANZICS, 2008
4. Nakagawa TA et al. Guidelines for the determination of brain death in infants and children: An update of the 1987 Task Force recommendations. Crit Care Med 2011; 39:2139-2155
5. Tibballs J. A critique of the apneic oxygenation test for the diagnosis of ““brain death””. Ped Crit Care Med. 2010 Jul;11(4):475-8

Pediatric Braindeath Guidelines Group 2011

Dr. Bala Ramachandran, Consultant and Head of the Department of Intensive Care & Emergency Medicine, Kanchi Kamakoti CHILDS Trust Hospital, Chennai Email: mdpicu@hotmail.com

Dr. Krishan Chugh, Head of the Department of Paediatrics, Fortis Hospital, Gurgaon Email: chugh.krishan@gmail.com

Dr. Sunit Singhi, Head of the Department of Paediatrics, Post Graduate Institute for Medical Education and Research, Chandigarh Email: sunit.singhi@gmail.com

Dr. Praveen Khilnani, Consultant Pediatric Intensivist, BLK Superspeciality Hospital, New Delhi Email: khilnanip@hotmail.com

Dr. V. Viswanathan, Consultant Pediatric Neurologist, Kanchi Kamakoti CHILDS Trust Hospital, Chennai Email: vishneuro@gmail.com

Dr. Joseph Mathew, Consultant Neurosurgeon, Christian Medical College, Vellore, TN Email: mathewcmc@gmail.com

Dr. Soonu Udani, Consultant Pediatric Intensivist, Hinduja Hospital, Mumbai Email: drsudani@gmail.com