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Brain death in infants and children according to current guidelines1:

  • Brain death guidelines: Defining brain death originates from the President's Commission of the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. For pediatric patients, the most recent brain death guidelines were published in 2011 by a multidisciplinary taskforce and are endorsed by the Society of Critical Care Medicine, the American Academy of Pediatrics, American Association of Critical Care Nurses, Child Neurology Society, and Society of Pediatric Neuroradiology. This definition of death is affirmed by the American Bar Association. Despite wide acceptance, no federal brain death law exists, so providers must review their state and institutional statutes and policies that may restrict this definition.

  • Brain death: Cessation of all neurologic functions of the brain due to a known, irreversible cause.

    • Clinical Diagnosis: This is a clinical diagnosis and must be made by a physician who has taken the history and completed the exam. Coma and apnea must coexist.

    • Clinical examination: Includes evaluation of coma, loss of brainstem functioning, and apnea.

  • Prerequisites for initiating brain death evaluation:

    • Irreversible coma with known cause: Although not considered ancillary studies, magnetic resonance imaging (MRI) or computerized tomography (CT) findings should show evidence of acute injury consistent with significant neurologic damage.

    • Hemodynamic and metabolic stability: Shock, hypotension, hypothermia, and severe metabolic disturbances that could affect neurologic function (i.e., glucose and electrolytes) must be corrected before initiating the exam.

    • Pharmacologic agents: Neuromuscular blockades, sedatives, barbiturates, opioids, and antiepileptics must be discontinued prior to the examination. For recently administered medications, adequate clearance should be allowed (based on half-life, organ dysfunction, and patient age).

    • Cardiopulmonary resuscitation: It may be necessary to wait 24 to 48 hours after cardiopulmonary arrest or severe acute brain injury due to patient instability or inconsistencies in neurologic examinations, as assessed by clinical judgment.

  • Number of examinations: Two examinations should be performed, separated by an observation period.

    • Neonates: For patients 37 weeks up to 30 days of age, the observation period between two exams should be 24 hours. Due to open sutures and fontanelles, neonates are less likely to have as significant intracranial hypertension, leading to cerebral ischemia and herniation, as older children.

      • Current guidelines do not include information for preterm infants.

    • Infants and children: For infants older than 30 days of age and children up to 18 years of age, the observation period between two exams should be 12 hours.

    • Special considerations: Should there be a desire to decrease the period of observation, an ancillary test may be considered.

  • Examiners: The clinical examinations should be performed by two different attending physicians, each with expertise in neurocritical care. Because the apnea exam is an objective exam, it may be performed by the same attending physician.

  • Neurologic examination: To assess loss of all brainstem reflexes. The following are consistent with cessation of brainstem function:

    • Absence of pupillary response: Midposition or fully dilated pupils that are nonreactive ...

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