Brain death declaration in
children
Dr Lokesh Lingappa
Consultant Paediatric Neurologist
Rainbow Children’s Hospital and Perinatal
Centre, Hyderabad
outline
• Limitations of current guidelines
• Testing process
• Are there differences adult/pediatric
• Problems of newborn testing
• Fallacies in intepretation of signs and testing
results
Key message
• The diagnosis of brain death should remain a
clinical one to be made at the bedside by
knowledgeable physicians who, in concert
with grieving families, make the most
agonizing of all life’s events (the death of a
child) as bearable as possible for all
concerned.
• Freeman JM, Ferry PC. New Brain Death
Guidelines in Children
Understanding limitations of pediatric brain death guidelines
• Guidelines are 20 years old
• Relied heavily upon EEG testing
• Guidelines did not specifically address the trauma
population
• Guidelines were based upon limited clinical experience
at the time of publication
• Guidelines were based upon age criteria
• No guidelines for neurologic death in neonates
• Waiting times have never been validated
History
• Determination of cause of death is necessary
to ensure the absence of treatable or
reversible conditions (ie, toxic or metabolic
disorders, hypothermia, hypotension, or
surgically remediable conditions).
Primary requirement
• Irreversibility of brain function cessation is
recognized
• Cause of coma is established and is sufficient to
account for the loss of brain function
• Possibility of recovery of any brain function is
excluded
• Cessation of brain function persists for an
appropriate period of observation or trial of
therapy
Diagnostic criteria
• Cessation of all brain function is recognized.
• Cerebral functions are absent (ie, unresponsiveness)
• Brainstem functions are absent:
1. Pupillary light reflex
2. Corneal reflex
3. Oculocephalic/oculovestibular reflex
4. Oropharyngeal reflex
5. Respiratory (apnea using an accepted apnea
testing procedure)
Confounding factors
• Complicating conditions are excluded
• Drug and metabolic intoxication
• Hypothermia
• Circulatory shock
• The patient has been monitored for an
appropriate observation period
Brainstem testing
Without confirmatory tests
With confirmatory tests
• 12 hours when the etiology • EEG: Irreversible loss of cortical
of the irreversible condition functions with ECS, together with
the clinical findings of absent
is well established brainstem functions, confirms
• 24 hours for anoxic injury to the diagnosis of brain death.
the brain • CBF: Absent CBF demonstrated
by radionuclide scanning or
intracranial 4-vessel cerebral
angiography in conjunction with
clinical determination of absence
of all brain function for at least 6
hours is diagnostic of brain death
Age dependent Observation period
age Hours between Recommended number
2 examination of EEGs
7 days to 2 months 48 2
2 months to 1 year 24 2
Beyond 1 year 12 None needed
Brain death and organ donation
Rainbow data 2009 29/79
Head injury 3
Near Drowning 2
CNS infection 9
Asphyxia 1
Metabolic disorders 9
Cerebrovascular disorders 1
Miscellaneous 4
Neonatal brain death
Neurologic death in the neonate
• “Brain death can be diagnosed in the term infant,
even at less than 7 days of age. An observation
period of 48 hours is recommended to confirm the
diagnosis. If an EEG is isoelectric or if a CBF study
shows no flow, then the observation period can be
shortened to 24 hours.”
• Ashwal. Brain death in the newborn. Clinics in
Perinatology 1997;24:859-879
Brain death in the neonate
• The younger the child, the more one needs to exercise
caution in determining brain death
• A second opinion from a colleague in pediatric critical care
or someone who is specialized in the neurosciences is
reasonable
• Physical examination criteria may require a longer
observation time based upon mechanism of cerebral
injury
• Use of ancillary test may be beneficial, but may also
confuse the issue in the neonate
• The absence of any form of repetitive,
sustained, purposeful activity on serial
examinations must be documented; likewise,
brain death must be differentiated from other
states of unconsciousness, such as the
vegetative state
preterm and term neonates
• several of the cranial nerve responses are not
fully developed.
• pupillary light reflex is absent before 29 to 30
weeks’ gestation,
• oculocephalic reflex may not be elicited before
32 weeks’ gestation
• Term and preterm infants are difficult to
examine because their smallness makes it
technically difficult to assess
Preterm and neonate
• Assessment of pupillary reactivity can be
compromised difficulties in gaining access –
incubator, by corneal injury, retinal
hemorrhages, and other anatomical factors
(swelling or partial fusion of the eyelids)
• smaller size of the pupils in newborns- make
assessment of the loss of pupillary reactivity
troublesome
Preterm and neonate
• Assessing the caloric response adequately more
difficult in neonates with a small external ear canal;
• both the oculocephalic (doll’s eye) and oculovestibular
(caloric) reflex should always be examined
• corneal reflex- easiest brain stem reflex to examine in
neonates and infants, it is often the least reliable
• Contact irritation, dehydration and maceration of the
cornea, use of lubricant drops, and use of analgesic
medications often adversely affect tactile sensory
information
MRI and CT of Neonates -HIE
Neuroimaging in Decision process
Neonatal CT Follow up CT brain
ANCILLARY TESTING
Considerations when diagnosing brain death in children
• Many times the cause of the child’s neurologic
demise is known
• Based upon presentation and examination many
times we know that there will be no hope for
survival or if the child does survive, the outcome
will be dismal
• The waiting period may be extended or decreased
depending upon social and family related issues
Ancillary testing
• Ancillary test that may aid in the diagnosis of
brain death
• EEG
• Cerebral angiography
• Radionuclide Scans
• Brainstem evoked responses
• Doppler sonography
Ancillary testing
• Ancillary tests may aid in the diagnosis of brain
death
– Ancillary tests can provide additional information to
help confirm brain death in situations where clinical
examination and apnea testing are not feasible or
cannot be completed because of undue circumstance
– Facial injury
– Acute lung injury
– Cardiovascular instability
Ancillary testing
Ancillary tests are not mandatory
• Ancillary tests may provide another layer of
comfort to the physician who is uncomfortable
declaring brain death on clinical exam alone
• Ancillary tests may reduce observation periods
thus increasing potential for retrieving viable
transplant tissue
• Ancillary tests may also delay or prolong
observation period
Recommendation for EEG
• the American Electroencephalographic Society
retrospectively surveyed 1665 patients with
electrocerebral silence (ECS), that is, no
evidence of brain electrical activity greater
than 2 µV between electrode pairs placed at a
distance of 10 cm or more, who were in
various levels of coma
• Only 3 of the 1665 patients recovered
cerebral function
EEG in infants and children
• shorter interelectrode distances;
• external artifacts in newborn ICUs and PICUs;
• Distances between the heart and the brain, making the
electrocardiographic contribution disproportionately
large
• reduced amplitude of cortical potentials in preterm and
term neonates
• longer duration of the effect of depressant medications
• greater tendency for suppression burst patterns in
infants with neurological disorders
Need for EEG
• Two cases of acute inflammatory
demyelinating polyradiculoneuropathy have -
at satisfied the clinical criteria for brain death
but had preserved EEG activity
• EEG has an important role in the confirmation
of brain death in such cases
Electrocerebral silence
EEG contd
• EEG patterns may show low-voltage theta or beta
activity or intermittent spindle activity
• Such activity in functionally dead brains may persist
for days
• Data from several studies indicate that the initial
EEG in brain dead children is isoelectric in 51% to
100% of patients (mean 83%).
• In most children who initially have EEG activity,
follow-up studies usually show evolution to ECS
• Typically, when the initial EEG
EEG contd
• ECS may occur soon after an infant or a child has
had a cardiac arrest.
• In infants in whom the initial EEG (typically
obtained 8-10 hours after cardiac arrest) showed
ECS, a repeat study 12 to 24 hours later may show
diffuse low-voltage activity
• Most of these infants die of complications - acute
catastrophic injury; the remaining survivors
permanent vegetative or minimally conscious state
EEG and drugs
• children, the most common medications causing
reversible loss of brain electrocortical activity
include barbiturates (eg, phenobarbital),
benzodiazepines, narcotics, and certain
• intravenous (thiopental, ketamine, midazolam) and
inhalation (halothane and isoflurane) anesthetics.
• Data from a study in 92 children indicated that
therapeutic levels of phenobarbital (ie, 15-40
μg/mL) do not affect the EEG
Need for repeat EEG
• Data on 37 of 53 brain-dead newborns in whom EEGs
were performed
• ECS (n = 21), very low voltage (n = 13), burst suppression
(n = 1), seizure activity (n = 1), and normal activity (n =
1).
• Almost all patients whose first EEG showed ECS had ECS
on the second study, and most patients who did not
show ECS on the first EEG did so on a repeat study
• The data suggest that only a single EEG showing ECS is
necessary to confirm brain death, provided the results of
the examination remain unchanged
Cerebral blood flow studies
• The absence of CBF in brain death is due
primarily to low cerebral perfusion pressure
and secondarily to release of vasoconstrictors
• from vascular smooth muscle
HMPO SPECT
Cerebral blood flow-neonatal issues
• Newborns have patent sutures and an open
fontanel, increases in ICP after acute injury are not
significant
• cascade of herniation from increased ICP and
reduced cerebral perfusion is less likely to occur in
newborns
• Brain death can be diagnosed in newborns (even
when younger than 7 days) if physician is aware of
the limitations of the clinical examination and
laboratory testing
Institutional Guidelines
• Does a policy regarding declaration of death exist in your
institution? Policy should provide guidelines allowing flexibility
and individuality for each child and their family
• Decisions regarding determination of brain death should be left
to the physician’s discretion within evolving standards of
medical care
• Who declares brain death in your institution?
• Concentrate your efforts on educating these individuals and
involve them in the establishment of institutional guidelines
Take home messages
Neurologic death occurs in children
• There are no unique legal issues in determining neurologic
death in children
• Neurologic death is a clinical diagnosis
• Ancillary studies are not mandatory, however they can assist in
determining neurologic death in certain situations
• Ancillary studies can reduce or prolong the recommended
observation period
• Observation periods have never been validated and are meant
to serve as guidelines only
• Neurologic death can occur and be diagnosed in infants less
than 7 days of age
Thank you
• One Class III study of 144 patients pronounced
• brain dead found 55% (95% confidence interval
• [CI] 47–63) of patients had retained plantar reflexes,
• either flexion or “stimulation induced undulating toe
• flexion.”22 Another study documented plantar flexion
• and flexion synergy bilaterally that persisted for
• 32 hours after the determination of brain death.23
ApneaTesting
• Absence of a breathing drive.
• Prerequisites: 1) normotension, 2) normothermia,
• 3) euvolemia, 4) eucapnia
• (PaCO2 35–45 mm Hg), 5) absence of
• hypoxia, and
• Procedure:
• • Adjust vasopressors to a systolic blood
• pressure 100 mm Hg.
• Neurology 74 8, 2010
Preoxygenate for at least 10 minutes with 100%
oxygen to a PaO2 200 mm Hg
• 10 breaths per minute- eucapnia
• Reduce PEEP to 5 cm H2O (oxygen desaturation
with decreasing PEEP may suggest difficulty
with apnea testing).
• SpO2> 95%, obtain a baseline blood gas (PaO2,
PaCO2, pH, bicarbonate, base excess)
• Disconnect the patient from the ventilator
Preserve oxygenation (e.g., place an insufflation catheter
through the endotracheal tube and close to the level of
the carina and deliver 100% O2 at 6 L/min).
• Look for respiratory movements - 8–10 minutes.
• Abort if systolic blood pressure decreases to 90 mm Hg.
• Abort if oxygen saturation measured by pulse oximetry
is 85% for 30 seconds.
• Retry procedure with T-piece, CPAP 10 cm H2O, and
100% O2 12L/min
• If no respiratory drive- repeat blood gas after
approximately 8 minutes.
• • If respiratory movements are absent and arterial
PCO2 is 60 mm Hg (or 20 mm Hg increase in arterial
PCO2), the apnea test result is positive
• • If test is inconclusive- patient is hemodynamically
stable, it may be repeated for a longer period of
time (10–15 minutes)
• after the patient is again adequately preoxygenated.
Take home messages
• Diagnosing brain death is not different in
children as compared to adult
• Newborn 34 week and above can be reliably
daignosed to have brain death within first week
of life
• Most newborn withdrawal of care is based on
future poor neurologic outcome rather than
brain death
• Most common ancillary testing required is EEG
