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Brain Death/Death by
Neurologic Criteria
C O N T I N UU M A UD I O
I NT E R V I E W A V AI L A B L E
Determination
ONLINE
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ABSTRACT
PURPOSE OF REVIEW: This article describes the prerequisites for brain
death/death by neurologic criteria (BD/DNC), clinical evaluation for
BD/DNC (including apnea testing), use of ancillary testing, and challenges
associated with BD/DNC determination in adult and pediatric patients.
Address correspondence to SUMMARY: The World Brain Death Project consensus statement is intended
Dr Ariane Lewis, Division of
to provide guidance for professional societies and countries to revise or
Neurocritical Care, Departments
of Neurology and Neurosurgery, develop their own protocols on BD/DNC, taking into consideration local
NYU Langone Medical Center, laws, culture, and resource availability; however, it does not replace local
530 First Ave, HCC-5A, New York,
NY 10016, ariane.kansas.lewis@
medical standards. To that end, pending publication of an updated
gmail.com. guideline on determination of BD/DNC across the lifespan, the currently
accepted medical standards for BD/DNC in the United States are the 2010
RELATIONSHIP DISCLOSURE:
Dr Lewis serves as a deputy American Academy of Neurology standard for determination of BD/DNC in
editor for Neurology and adults and the 2011 Society of Critical Care Medicine/American Academy
Seminars in Neurology. of Pediatrics/Child Neurology Society standard for determination of
Dr Kirschen has received
research/grant support from BD/DNC in infants and children.
the Neurocritical Care Society.
UNLABELED USE OF
PRODUCTS/INVESTIGATIONAL INTRODUCTION
D
USE DISCLOSURE:
eath can be declared using cardiopulmonary or neurologic criteria
Drs Lewis and Kirschen report
no disclosures. (traditionally termed brain death). Brain death/death by neurologic
criteria (BD/DNC) is accepted as death throughout much of the
© 2021 American Academy
world.1,2 The incidence of BD/DNC declaration worldwide is
of Neurology. unknown, but epidemiologic studies have found that 2% to 12% of
GENERAL PRINCIPLES
BD/DNC evaluations should only be performed by licensed practitioners who are
experienced in caring for patients with devastating brain injuries and have been
trained in determination of BD/DNC and in counseling families at the end of
CONTINUUMJOURNAL.COM 1445
IV = intravenous.
a
Practitioners must be aware of medications that could lead to false-positive declaration of brain
death/death by neurologic criteria. Examples are provided here, but this list is not exhaustive.
CONTINUUMJOURNAL.COM 1447
following completion of the clinical examination and apnea test.2 ● Numerous spinally
The brainstem reflexes included in the 2010 AAN and WBDP standards are mediated reflexes have
the pupillary, corneal, oculocephalic, oculovestibular, gag, and cough reflexes.2,10 been observed in patients
The 2011 SCCM/AAP/CNS standard includes all of these reflexes except the who meet clinical criteria for
brain death/death by
oculocephalic reflex. The 2011 SCCM/AAP/CNS standard, like the WBDP neurologic criteria, including
standard, also notes the need to confirm absence of the sucking and rooting myoclonus, spontaneous
reflexes in neonates and infants.2,12 To be compatible with BD/DNC, the extensor posturing,
pupillary reflex assessment should demonstrate fixed midsize or dilated pupils intermittent head turning,
slow flexion then extension
bilaterally that are unresponsive to direct or consensual stimulation.2,10,12 A
of the toes (undulating toe),
magnifying glass can help facilitate assessment for a pupillary response. Use of and isolated thumb
a pupillometer may also be considered, but this has not been validated. The extension (thumbs-up sign).
corneal reflex is assessed by applying light pressure to the cornea at the external
border of the iris with a cotton swab on a stick to evaluate for eyelid movement,
which is absent in BD/DNC.2,10,12 The oculocephalic reflex is tested by briskly
rotating the head horizontally and evaluating for eye movements, the presence of
which is not compatible with BD/DNC.2,10,12 This should not be done if
evidence or suspicion of cervical injury exists.2,10 The oculovestibular reflex tests
the same nerves as the oculocephalic reflex and is, in fact, more sensitive. Thus,
in the setting of known or suspected cervical trauma when the oculocephalic
reflex cannot be performed, BD/DNC can still be declared clinically if the
oculovestibular reflex is absent.2 Before testing the oculovestibular reflex, the
auditory canal should be inspected to confirm it is patent and that the tympanic
membrane is intact (note that a ruptured membrane would lead to a stronger
response, if present, but could increase the risk of meningitis, which could be
harmful if the examination is not consistent with BD/DNC). With the head of
bed elevated to 30 degrees, 50 mL to 60 mL of cold water should be injected into
the ear while the eyes are monitored for movement for at least 1 minute. This
should be repeated on the other side following a 5-minute interval that facilitates
equilibration of the endolymph temperature.2,10,12 The gag and cough reflexes are
assessed by stimulating both sides of the posterior pharynx and the
tracheobronchial wall.2,10,12 In neonates and infants, the sucking reflex is assessed
by placing a gloved finger in the baby’s mouth to see if sucking occurs (ie, if the
lips close around the finger) and the rooting reflex is assessed by stroking the
cheeks bilaterally to see if the baby’s head moves (which indicates a
positive response).2,12
CONTINUUMJOURNAL.COM 1449
Irreversibility Establish that brain injury is Establish that brain injury is Establish that brain injury is
irreversible irreversible irreversible
Neuroimaging should Suggested to ensure
demonstrate evidence of an neuroimaging evidence of
acute central nervous system intracranial hypertension is
injury consistent with the present or intracranial
profound loss of brain pressure measurements equal
function or exceed mean arterial
pressure
It is not necessary to perform
interventions to decrease
intracranial pressure simply for
the purpose of demonstrating
irreversibility of the clinical
state
Temperature >36 °C (96.8 °F) >35 °C (95 °F) ≥36 °C (96.8 °F)
Blood pressure Systolic blood pressure Systolic or mean arterial blood Systolic blood pressure
≥100 mm Hg pressure should not be less ≥100 mm Hg or mean arterial
than 2 standard deviations pressure ≥60 mm Hg in adults
below age-appropriate norms and age-appropriate in
pediatric patients
Exclude Ensure presence of four twitches Evaluate nerve function with a Exclude pharmacologic
pharmacologic with maximum ulnar stimulation nerve stimulator paralysis with a peripheral
paralysis nerve stimulator/train-of-
foura or by demonstrating
presence of deep tendon
reflexes
Laboratory Exclude severe electrolyte, acid- Identify and treat reversible Correct severe metabolic,
parameters base, and endocrine disturbance causes of coma that interfere acid-base, and endocrine
with the clinical evaluation, derangements that could
including severe electrolyte impact the examination
derangements,
hyperglycemia or
hypoglycemia, severe pH
disturbances, severe hepatic
or renal dysfunction, and
inborn errors of metabolism
CONTINUUMJOURNAL.COM 1451
Qualifications of Not stated Attending physicians who are Practitioners who have completed
examiners qualified and competent to training, are licensed to
perform the brain death independently practice medicine,
examination and are trained in determination of
BD/DNC, counseling families at
Specialty of pediatric critical care,
end of life, and managing
pediatric neurology, neonatology,
devastating brain injuries
pediatric anesthesiology with
critical care training, pediatric Pediatric patients should be
neurosurgery, or pediatric trauma evaluated by experienced
surgery pediatric clinicians with specialty
in neonatology, neurosurgery,
Adult specialists should have
pediatric critical care, pediatric
appropriate neurologic and critical
neurointensive care, pediatric
care training to diagnose brain
neurology, or trauma surgery
death when caring for the pediatric
patient from birth to 18 years of age
Observation Not stated 12 hours (>30 days-18 years of age) If two examinations are
period between performed, an observation period
24 hours (37 weeks estimated
examinations between examinations is
gestational age to 30 days)
unnecessary
APNEA TESTING
Upon completion of the clinical evaluation, if a patient is found to be comatose
and have absent brainstem reflexes, barring a contraindication, the next
step is apnea testing (TABLE 12-4). Contraindications to apnea testing described
in the 2010 AAN, 2011 SCCM/AAP/CNS, and WBDP standards include severe
obesity or chronic obstructive pulmonary disease (2010 AAN standard), high
cervical spine injury (2011 SCCM/AAP/CNS and WBDP standards), chronic
hypoxemia due to cyanotic heart disease (WBDP standard), or any safety
concerns (2011 SCCM/AAP/CNS standard).2,10,12
The purpose of apnea testing is to determine if the medullary chemoreceptors,
which should stimulate respiration in the setting of hypercarbia and acidosis, are
functional.2,10,12,17 Following preoxygenation, the apnea test is performed by
removing intermittent mechanical ventilation and observing for spontaneous
respirations. In adults, hypoxia is avoided by placing an insufflation catheter that
is less than 70% of the endotracheal tube diameter down the endotracheal tube
and delivering up to 6 L/min of oxygen (these limits are in place to decrease the
risk of a pneumothorax); continuous positive airway pressure (CPAP) can also
be used if needed.2,10,17 In infants and children, tracheal insufflation generally is
not performed because of a heightened concern that their lower lung capacity
can put them at higher risk for washout of carbon dioxide, which can delay or
prevent completion of the test, or barotrauma to the lungs.2,17 Thus, in this age
group, oxygenation is provided via a T-piece circuit connected to the
endotracheal tube with a functioning positive end-expiratory pressure valve or
CPAP with a flow-inflating anesthesia bag or ventilator.2,12,18
Although the carbon dioxide level and pH at which the medullary
chemoreceptors would definitively stimulate respiration if they were functional
is unknown, the 2010 AAN standard indicates that the target PaCO2 is ≥60 mm
Hg or ≥20 mm Hg above baseline and the 2011 SCCM/AAP/CNS standard
indicates that the target PaCO2 is ≥60 mm Hg and ≥20 mm Hg above
baseline.10,12,17 However, the meaning of “baseline” is unclear in both of these
standards and, similar to the majority of standards for BD/DNC around the
CONTINUUMJOURNAL.COM 1453
Contraindications Prior evidence of carbon High cervical spine injury High cervical spine injury
dioxide retention (severe
Safety concerns for the Chronic hypoxemia due to
obesity or chronic obstructive
patient (eg, high oxygen cyanotic heart disease
pulmonary disease)
requirement or ventilator
settings)
Technique Preoxygenate for at least Preoxygenate for 5-10 minutes Preoxygenate for at least
10 minutes with 100% oxygen to with 100% oxygen 10 minutes with 100% oxygen
PaO2 >200 mm Hg
Ensure normalization of the Ensure PaCO2 35-45 mm Hg
Ensure PaCO2 35-45 mm Hg pH and PaCO2, measured by
Preserve oxygenation with an
arterial blood gas analysis
Reduce ventilator frequency to insufflation catheter placed
10 breaths per minute Discontinue intermittent through the endotracheal tube
mandatory ventilation (except in neonates, infants, or
Reduce positive end-expiratory
young children)
pressure to 5 cm H2O Attach a T-piece circuit or a
self-inflating bag valve Consider use of CPAP on the
Disconnect the ventilator
system such as a Mapleson ventilator or via resuscitation bag
Preserve oxygenation with an circuit to the endotracheal
insufflation catheter placed tube or use CPAP if needed
through the endotracheal tube
delivering 100% oxygen at 6 L/min
Use T-piece circuit or
continuous positive airway
pressure (CPAP), if needed
Apnea testing PaCO2 ≥60 mm Hg or ≥20 mm Hg PaCO2 ≥60 mm Hg pH <7.3 and PaCO2 ≥60 mm Hg
target above baseline and ≥20 mm Hg above unless the patient has preexisting
baseline hypercapnia, in which case target
should be ≥20 mm Hg above
baseline, if known
CONTINUUMJOURNAL.COM 1455
tests.2,10,12 The 2010 AAN and WBDP standards consider transcranial Doppler to
be an acceptable ancillary test in adults. Given that transcranial Doppler has not
been validated as an ancillary test in pediatrics, it is not included in the 2011
SCCM/AAP/CNS standard, and the WBDP standard recommends it not be used
in pediatrics until more studies determine its utility in this population.2,10,12
Although EEG was included in the 1968 Harvard standard and is considered an
acceptable ancillary test in the 2010 AAN and 2011 SCCM/AAP/CNS standards,
the WBDP standard suggests it only be used if mandated by regional policy or
law or if craniovascular impedance is affected by an opening in the skull (such as
This patient had severe hypoxic-ischemic brain injury after a prolonged COMMENT
cardiac arrest due to myocarditis and was cannulated onto venoarterial
ECMO. BD/DNC evaluation was appropriately initiated after waiting a
sufficient time to allow for clearance of sedating medications and after
meeting all prerequisites. Following completion of the clinical examination,
the apnea test was performed on ECMO. The patient was taken off
mechanical ventilation, and the sweep gas flow was reduced to allow
carbon dioxide to accumulate in the blood. The practitioners ensured that
the PaCO2 levels from both the arterial catheter and the ECMO circuit
postoxygenator were above the BD/DNC thresholds. If the patient had
been too hemodynamically unstable to undergo apnea testing or the test
could not be completed because of hypotension or hypoxemia, ancillary
testing could have been performed.
CONTINUUMJOURNAL.COM 1457
FIGURE 12-2
Examples of what to say when talking to families about brain death/death by neurologic
criteria. Communication about brain death/death by neurologic criteria can be challenging.
These examples can help to educate families while empathizing with them about their family
member’s catastrophic brain injury.
Patience and empathy are needed when discussing BD/DNC with a COMMENT
patient’s family. Education, including a review of imaging and
demonstration of the neurologic examination, helps families come to terms
with the severity and irreversibility of a patient’s catastrophic brain injury.
Although consent is not needed to conduct a BD/DNC evaluation, it is
appropriate to allow a family a brief period of time to process the situation.
Multidisciplinary support for a patient’s family from both hospital staff and
the family’s community can be beneficial.
CONTINUUMJOURNAL.COM 1459
Need for consent No obligation to obtain consent Not discussed No obligation to obtain consent
before the clinical evaluation,
apnea testing, or ancillary testing
CONTINUUMJOURNAL.COM 1461
measured arterial pH and carbon dioxide represent the values in the cerebral
circulation.2 Oxygenated blood can arise from native cardiac output (after gas
exchange in the native lungs) and mix with oxygenated blood from the ECMO
circuit. Therefore, when a patient is on venoarterial ECMO, arterial blood should
be sampled simultaneously from both the patient’s arterial catheter and the
ECMO circuit postoxygenator to ensure the pH and carbon dioxide in the
cerebral circulation exceed the BD/DNC thresholds.2 CASE 12-2 illustrates apnea
testing for a patient on venoarterial ECMO. The WBDP standard does not
address ancillary testing for patients on ECMO, but a 2020 review of the
literature noted that all the ancillary tests used in patients who are not on ECMO
have been used in patients on ECMO.21
CONTINUUMJOURNAL.COM 1463
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