Paeds · neurology-neurodisability-and-neuromuscular
Brain death, death by neurological criteria and organ donation
Also known as Death by neurologic criteria · Brain death determination · Brainstem death · Neurological determination of death · Donation after brain death
Fellowship guide to brain death, death by neurological criteria and organ donation in children. Covers the irreversible cessation of all function of the entire brain including the brainstem, the difference between circulatory and neurological death and the whole-brain versus brainstem concept, the catastrophic prerequisites of a known irreversible cause with confounders corrected including normothermia of a core temperature at least 36 degrees Celsius and a blood pressure normal for age, the bedside examination of coma with absent brainstem reflexes, the apnoea test positive when there is no respiratory effort and the PaCO2 reaches at least 60 mmHg or rises by at least 20 mmHg from baseline, the two clinical evaluations performed by independent senior clinicians separated by an observation period of 48 hours for term neonates up to 30 days and 24 hours for infants and children, the ancillary tests of cerebral angiography and nuclear brain scan and transcranial Doppler and EEG, the declaration of death and the donation after brain death pathway with donor management, and the ANZICS, AAN and World Brain Death Project evidence on regional practice.
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- Brain death is never diagnosed in a child whose core temperature is below 36 degrees Celsius, because hypothermia suppresses brainstem reflexes and mimics death
- A systolic blood pressure below the normal range for age invalidates the examination, because hypotension alone abolishes brainstem reflexes
- A patient on a barbiturate infusion or a neuromuscular blocker cannot be declared brain dead on clinical examination alone, and the drug must be cleared first or an ancillary test used
- Any respiratory effort during the apnoea test means the test is negative and brain death is not present, and the ventilator is reconnected at once
- Brain death determination is not made in neonates born before 37 weeks gestational age, and is applied cautiously in the term neonate
- The clinician who declares death must not be part of the transplant team, to protect the dead donor rule and the family trust
- The cause of the coma must be known and irreversible before any testing begins, because a reversible encephalopathy must never be mistaken for brain death
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- Defines brain death as the irreversible cessation of all function of the entire brain including the brainstem, and recognises it as a legal definition of death
- States that the prerequisites must be met before any testing, namely a known and irreversible catastrophic cause with hypothermia, hypotension, sedatives and metabolic disturbance corrected
- Identifies the apnoea test as positive when there is no respiratory effort and the PaCO2 reaches at least 60 mmHg or rises by at least 20 mmHg from baseline
- Explains the whole-brain versus the brainstem concept of death and how the ANZICS framework applies the determination across the term neonate, infant, child and adolescent
- Applies the bedside examination of coma with absent brainstem reflexes, the apnoea test, and the two clinical evaluations by independent senior clinicians separated by an observation period
- Selects an ancillary test such as cerebral angiography, nuclear brain scan, transcranial Doppler or EEG when the examination or apnoea test cannot be completed or a confounder persists
- The prerequisites of a known irreversible cause, normothermia of a core temperature at least 36 degrees Celsius, and a blood pressure normal for age before testing begins
- The apnoea test positive when the PaCO2 reaches at least 60 mmHg or rises by at least 20 mmHg from baseline with no respiratory effort
- Two examinations by independent senior clinicians, with the observation period of 48 hours for the term neonate up to 30 days and 24 hours for the infant and child
- Runs the full bedside brain death determination including the prerequisite checks, the brainstem reflex examination, and the apnoea test
- Counsels the family through the declaration of death, the prognostic finality, and the organ donation conversation in partnership with the donation team
- Coordinates the donor management after death is declared, including the dead donor rule and the separation of the treating team from the transplant team
- Level 1: Recognition that brain death is the irreversible loss of all brain and brainstem function and is a legal definition of death distinct from circulatory death
- Level 2: Application of the prerequisites, the bedside examination of absent brainstem reflexes, and the apnoea test with the correct PaCO2 thresholds
- Level 3: Coordination of the two clinical evaluations, the observation period, the ancillary testing when needed, and the organ donation pathway and family support
- The definition of brain death as irreversible cessation of all function of the entire brain including the brainstem, and the legal equivalence to circulatory death
- The prerequisites and confounders, the brainstem reflex examination, and the apnoea test with a PaCO2 of at least 60 mmHg or a rise of at least 20 mmHg
- The evidence from the AAN guideline of Wijdicks, the pediatric guideline of Nakagawa, the 2023 consensus guideline of Greer, and the World Brain Death Project
- Structured performance of the brainstem reflex examination and the apnoea test in a ventilated child in the intensive care unit
- Recognition of the prerequisites and confounders that must be corrected before the determination can proceed
- Communication with the family on the declaration of death, the finality of the prognosis, and the organ donation discussion
- Brain death as the irreversible cessation of all function of the entire brain including the brainstem and a legal definition of death in the child
- The prerequisite corrections and the bedside examination with the apnoea test and its PaCO2 thresholds
- The two clinical evaluations, the observation period, the ancillary tests, and the organ donation after brain death pathway
- Recognition that brain death is a legal definition of death requiring a known irreversible cause and the correction of all confounders before testing
- Performance of the brainstem reflex examination and the apnoea test with the correct thresholds, and the requirement for two evaluations
- Coordination of donor management and organ donation after the declaration of death in partnership with the donation and transplant teams
- Canadian approach to the neurological determination of death using the catastrophic brain injury prerequisite and the two-clinician examination
- The bedside examination of absent brainstem reflexes and the apnoea test with the PaCO2 thresholds from the Canadian forum recommendations
- The pediatric donation after circulatory determination of death pathway alongside donation after brain death and the donor management principles
Overview & Definition
A child who has suffered a catastrophic and irreversible brain injury may reach a point where the entire brain, including the brainstem, has permanently ceased to function. At that point the law regards the child as dead, even though a ventilator keeps the heart beating. Brain death, or death by neurological criteria, is the irreversible cessation of all function of the entire brain including the brainstem. It is one of the two legal definitions of human death. The other is the irreversible cessation of the circulatory and the respiratory function. [4]
The bedside question is never whether the heart is beating, because the ventilated brain-dead child often has a strong pulse. The question is whether every trace of brain and brainstem function has been lost forever. That loss is the legal line at which death is declared and at which organ donation can begin. The determination rests on a deliberate and reproducible sequence, designed to prevent the one error that must never occur. That error is the declaration of death in a child whose brain is not truly dead. [4]
Before any testing begins, the clinician must establish that a known and irreversible catastrophic cause has produced a deep coma. Every reversible factor that can mimic brain death must be sought and corrected. Only then is the bedside examination performed, looking for the total absence of consciousness and of every brainstem reflex. The apnoea test follows, asking whether any drive to breathe survives when the carbon dioxide is allowed to rise. The American Academy of Neurology set out the adult criteria in its guideline reported by Wijdicks and colleagues. Nakagawa and colleagues extended the framework to infants and children, and the 2023 consensus guideline of Greer and colleagues harmonised the two. [1][2][3]
Three ideas make this topic central to the paediatric fellowship examination. The determination of brain death is a legal declaration of death, and it carries the same finality as a circulatory death, so the prerequisites and the examination must be performed without error. The apnoea test, with its carbon dioxide thresholds, is the most testable single step and the one that converts a suspicion into a determination. The organ donation that follows is the one pathway by which the death of one child can save several other lives, and it demands a rigorous separation of the treating team from the transplant team so that the trust of the family is never broken. The World Brain Death Project, reported by Greer and colleagues, set out the global common ground on all of this. [4]
References10ShowHide
- [1]Wijdicks EF, Varelas PN, Gronseth GS, 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.PMID 20530327
- [2]Nakagawa TA, Ashwal S, Mathur M, et al Clinical report—Guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations. Pediatrics, 2011.PMID 21873704
- [3]Greer DM, Kirschen MP, Lewis A, et al Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline. Neurology, 2023.PMID 37821233
- [4]Greer DM, Shemie SD, Lewis A, et al Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project. JAMA, 2020.PMID 32761206
- [5]Lewis A, Bakkar A, Kreiger-Benson E, et al Determination of death by neurologic criteria around the world. Neurology, 2020.PMID 32576632
- [6]Braksick SA, Robinson CP, Gronseth GS, et al Variability in reported physician practices for brain death determination. Neurology, 2019.PMID 30804063
- [7]Wang HH, Varelas PN, Henderson GV, et al Improving uniformity in brain death determination policies over time. Neurology, 2017.PMID 28077490
- [8]Nakagawa TA, Ashwal S, Mathur M, 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.PMID 21849823
- [9]Weiss MJ, Hornby L, Rochwerg B, et al Canadian Guidelines for Controlled Pediatric Donation After Circulatory Determination of Death-Summary Report. Pediatr Crit Care Med, 2017.PMID 28925929
- [10]Shemie SD, Doig C, Dickens B, et al Severe brain injury to neurological determination of death: Canadian forum recommendations. CMAJ, 2006.PMID 16534069