Use of Ancillary Tests When Determining Brain Death in Pediatric Patients in the United States

Although pediatric brain death guidelines stipulate when ancillary testing should be used during brain death determination, little is known about the way these recommendations are implemented in clinical practice. We conducted a survey of pediatric intensivists and neurologists in the United States on the use of ancillary testing. Although most respondents noted they only performed an ancillary test if the clinical examination and apnea test could not be completed, 20% of 195 respondents performed an ancillary test for other reasons, including (1) to convince a family that objected to the brain death determination that a patient is truly dead (n = 21), (2) personal preference (n = 14), and (3) institutional requirement (n = 5). Our findings suggest that pediatricians use ancillary tests for a variety of reasons during brain death determination. Medical societies and governmental regulatory bodies must reinforce the need for homogeneity in practice.

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Performing the Brain Death Examination and the Declaration of Pediatric Brain Death

Journal of Pediatric Intensive Care ◽

10.1055/s-0037-1604013 ◽

2017 ◽

Vol 06 (04) ◽

pp. 229-233 ◽

Cited By ~ 1

Author(s):

Melissa Porter ◽

Susan Martin

Keyword(s):

Intensive Care ◽

Brain Death ◽

Pediatric Intensive Care ◽

Care Providers ◽

Apnea Test ◽

Brain Death Determination ◽

Definition Of ◽

Death Determination ◽

Pediatric Brain ◽

The Brain

AbstractDeclaration of brain death is a clinical diagnosis made by the absence of neurological function in a comatose patient secondary to a known irreversible cause. Brain death determination is not an infrequent process in pediatric intensive care units. It is important that pediatric intensive care providers understand the definition of brain death and intensivists are able to implement brain death testing. The following is a narration detailing the process of brain death determination by physical examination. First, the prerequisites that determine patients' eligibility for brain death testing will be outlined. Next, each part of the physical exam, including the apnea test, will be described in detail. Finally, how the declaration of brain death is made is stated. In addition, special considerations and ancillary testing will be briefly highlighted.

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Brain Death, Organ Donation, and Transplantation

Neurocritical Care ◽

10.1093/med/9780199375349.003.0026 ◽

2018 ◽

pp. 276-285

Author(s):

Hilary H. Wang ◽

David M. Greer

Keyword(s):

Brain Death ◽

Organ Donation ◽

The United States ◽

Apnea Test ◽

Unit Management ◽

Legal Context ◽

History Of ◽

Brain Death Determination ◽

Brain Dead ◽

Death Determination

This chapter reviews the history of brain death determination, current guidelines for performing the brain death examination including the apnea test, details of apnea testing, the role of brain dead donors in organ donation, physiologic changes seen in brain dead patients, and the relevant challenges in intensive care unit management of such patients for donor organ optimization. The goal of this chapter is to provide clear guidance for a critical care provider to perform an accurate and thorough brain death examination and to further the reader’s understanding of the historical and legal context surrounding brain death and organ donation in the United States.

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Beliefs and Brain Death

10.1093/med/9780190662493.003.0004 ◽

2017 ◽

Author(s):

Eelco F.M. Wijdicks

Keyword(s):

United States ◽

Native American ◽

Brain Death ◽

Cultural Diversity ◽

Organ Donation ◽

The United States ◽

Neurological Injury ◽

Brain Death Determination ◽

Death Determination

Globalization has increased cultural diversity in many communities. This has immediate implications for care of patients with catastrophic neurological injury and later discussions of brain death and organ donation. While the major religions in the United States—Christianity, Islam, and Judaism—have taken a tolerant position in these matters, some denominations within them are vigorously opposed to it. This chapter presents a range of cultural and religious views of brain death determination and organ donation. In addition to the three major religions, Buddhist and native American views regarding brain death determination as well as organ donation are discussed. Conflict resolution over organ donation is discussed along with the role of clergy in mediating such conflicts between families and medical staff.

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Variability Across Countries for Brain Death Determination in Adults

10.21203/rs.3.rs-70795/v1 ◽

2020 ◽

Author(s):

Fang Yuan ◽

Weijun Zhang ◽

Wanxin Wen ◽

Huiping Li ◽

Shibiao Wu ◽

...

Keyword(s):

Brain Death ◽

Predictive Value ◽

Diagnostic Procedures ◽

Apnea Test ◽

Ancillary Test ◽

Brain Death Determination ◽

Technical Specifications ◽

Sensitivity Specificity ◽

Death Determination ◽

Prospective Database

Abstract Background: Currently there is variability in diagnostic procedures across countries. Our aim was to compare guidelines of brain death determination in adults among five countries: China, UK, US, France, and Germany.Method: This is a retrospective study based on a prospective database of consecutive coma patients who received brain death determination. The technical specifications, completion rates, and positive rates of brain death determination according to criteria of different countries were compared. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each ancillary test for the identification of brain death diagnosed according to different criteria were investigated.Results: One hundred and ninety-nine patients who received brain death determination from June 2018 to June 2020 were included in this study. One hundred and thirty-one (65.8%) patients were diagnosed with brain death according to French criteria, 132 (66.3%) according to Chinese criteria, and 135 (67.7%) according to criteria of US, UK, and Germany. The sensitivity and PPV of EEG (92.2% - 92.3%) and SLSEP (95.5% - 98.5%) were higher than TCD (84.3% - 86.0%), and all these three tests have a very low specificity and NPV.Conclusions: The duration of apnea test and requirements of ancillary tests vary among countries. The discrepancy in brain death determination between clinical assessments and additional confirmation of ancillary tests is small.

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Variability in Diagnosing Brain Death at an Academic Medical Center

Neuroscience Journal ◽

10.1155/2017/6017958 ◽

2017 ◽

Vol 2017 ◽

pp. 1-7 ◽

Cited By ~ 8

Author(s):

Ashutosh Pandey ◽

Pradeep Sahota ◽

Premkumar Nattanmai ◽

Christopher R. Newey

Keyword(s):

Brain Death ◽

Medical Center ◽

Academic Medical Center ◽

Time Of Death ◽

Apnea Test ◽

Hospital Policy ◽

Strict Adherence ◽

Ancillary Test ◽

Brain Death Determination ◽

Death Determination

Objective. Research continues to highlight variability in hospital policy and documentation of brain death. The aim of our study was to characterize how strictly new guidelines of American Academy of Neurology (AAN) for death by neurological criteria were practiced in our hospital prior to appointment of neurointensivists. Method. This is a retrospective study of adults diagnosed as brain dead from 2011 to 2015. Descriptive statistics compared five categories: preclinical testing, neurological examination, apnea tests, ancillary test, and documentation of time of death. Strict adherence to AAN guidelines for brain death determination was determined. Result. 76 patients were included in this study. Preclinical prerequisites were fulfilled in 53.9% and complete neurological examinations were documented in 76.3%. Apnea test was completed in 39.5%. Ancillary test was completed in 29.8%. Accurate documentation of time of death occurred in 59.2%. Overall, strict adherence to current AAN guidelines for death by neurological criteria was correctly documented in 38.2%. Conclusion. Our study shows wide variability in diagnosing brain death. These findings led us to update our death by neurological criteria policy and increase awareness of brain death determination with the goal of improving our documentation following current AAN guidelines.

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Faculty Opinions recommendation of Variability in pediatric brain death determination and documentation in southern California.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1109262.565271 ◽

2008 ◽

Author(s):

Charles Schleien

Keyword(s):

Brain Death ◽

Southern California ◽

Brain Death Determination ◽

Death Determination ◽

Pediatric Brain

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Analyzing EEG of Quasi-Brain-Death Based on Dynamic Sample Entropy Measures

Computational and Mathematical Methods in Medicine ◽

10.1155/2013/618743 ◽

2013 ◽

Vol 2013 ◽

pp. 1-6 ◽

Cited By ~ 4

Author(s):

Li Ni ◽

Jianting Cao ◽

Rubin Wang

Keyword(s):

Brain Death ◽

Real Time ◽

Time Window ◽

Approximate Entropy ◽

Sample Entropy ◽

Well Performance ◽

Entropy Measures ◽

Brain Death Determination ◽

Death Determination ◽

The Brain

To give a more definite criterion using electroencephalograph (EEG) approach on brain death determination is vital for both reducing the risks and preventing medical misdiagnosis. This paper presents several novel adaptive computable entropy methods based on approximate entropy (ApEn) and sample entropy (SampEn) to monitor the varying symptoms of patients and to determine the brain death. The proposed method is a dynamic extension of the standard ApEn and SampEn by introducing a shifted time window. The main advantages of the developed dynamic approximate entropy (DApEn) and dynamic sample entropy (DSampEn) are for real-time computation and practical use. Results from the analysis of 35 patients (63 recordings) show that the proposed methods can illustrate effectiveness and well performance in evaluating the brain consciousness states.

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The effect of incorporating an arterial pH target during apnea test for brain death determination

Journal of Intensive Care ◽

10.1186/s40560-020-00522-8 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Ibrahim Migdady ◽

Moein Amin ◽

Aaron Shoskes ◽

Catherine Hassett ◽

Sung-Min Cho ◽

...

Keyword(s):

Brain Death ◽

Cleveland Clinic ◽

Apnea Test ◽

Arterial Ph ◽

Common Etiology ◽

Brain Death Determination ◽

Blood Gas Analyses ◽

The Impact ◽

Death Determination ◽

Current Guidelines

Abstract Background Persistent apnea despite an adequate rise in arterial pressure of CO2 is an essential component of the criteria for brain death (BD) determination. Current guidelines vary regarding the utility of arterial pH changes during the apnea test (AT). We aimed to study the effect of incorporating an arterial pH target < 7.30 during the AT (in addition to the existing PaCO2 threshold) on brain death declarations. Methods We performed retrospective analysis of consecutive adult patients who were diagnosed with BD and underwent AT at the Cleveland Clinic over the last 10 years. Data regarding baseline and post-AT blood gas analyses were collected and analyzed. Results Ninety-eight patients underwent AT in the study period, which was positive in 89 (91%) and inconclusive in 9 (9%) patients. The mean age was 50 years old (standard deviation [SD] 16) and 54 (55%) were female. The most common etiology BD was hypoxic ischemic brain injury (HIBI) due to cardiac arrest (42%). Compared to those with positive AT, patients with inconclusive AT had a higher post-AT pH (7.24 vs 7.17, p = 0.01), lower PaO2 (47 vs 145, p < 0.01), and a lower PaCO2 (55 vs 73, p = 0.01). Among patients with a positive AT using PaCO2 threshold alone, the frequency of patients with post-AT pH < 7.30 was 95% (83/87). Conclusion Implementing a BD criteria requiring both arterial pH and PaCO2 thresholds reduced the total number of positive ATs; these inconclusive cases would have required longer duration of AT to reach both targets, repeated ATs, or ancillary studies to confirm BD. The impact of this on the overall number BD declarations requires further research.

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