SAN FRANCISCO — Pediatric brain-death guidelines were followed to the letter in only 1 case of 142 that resulted in organ donation during a 5-year period in Southern California, Dr. Mudit Mathur reported at the annual congress of the Society of Critical Care Medicine.
“There is an urgent need for the update and revision of these criteria. … What we need are clear, consistent, uniform, and reliable guidelines in terms of brain-death diagnosis, declaration, documentation, and reporting,” said Dr. Mathur, a pediatric critical care specialist at Loma Linda (Calif.) University Children's Hospital.
The guidelines, issued in 1987 by the American Academy of Pediatrics Task Force on Brain Death in Children, call for the evaluation of 14 clinical elements in determining that a child is brain dead (Arch. Neurol. 1987;44:587–8). (See sidebar.)
A review showed that the charts of the 142 children declared to be brain dead contained documentation of a median of 6 of the 14 elements considered crucial to establishing brain death. Involvement of a pediatric intensivist in the diagnosis did not result in more elements being recorded.
The AAP guidelines call for the diagnosis of brain death to be based on findings from two exams to be conducted at separate times; the physician conducting each exam should evaluate the patient on the 14 clinical elements. The review's findings showed that on the first exam, charts from only 8 of the 142 cases included documentation of more than 10 elements. On the second exam, charts from only three cases included notes on more than 10 elements. In only one case were all 14 elements recorded at both exams.
Also, among the cases studied, the correct age-specific interval was followed only 12% of the time.
Dr. Mathur and his colleagues reviewed the charts of all children referred to OneLegacy, Southern California's organ procurement organization, from January 2000 to December 2004. OneLegacy serves seven Southern California counties that together have a population of 18 million people, 220 hospitals, and 14 transplant centers. Of 277 patients referred during the 5-year period, 142 had organ donation. A majority of those children (80%) were 1 year of age or older.
About a third of the patients were seen in children's hospitals, another third in community hospitals, and the rest in county hospitals, university-affiliated hospitals, and combined adult and children's hospitals. Two-thirds of the patients received their care in a pediatric ICU.
Neurosurgeons and pediatric intensivists were each involved in about 29% of the exams, with internists, neurologists, and/or other physicians involved in the remainder.
Measurement of cerebral blood flow was used to confirm brain death in 73% of 106 cases. Brain death was confirmed by electroencephalogram in 22% of cases. Patients had both exams in only six cases.
“It's not surprising why we have a preference for relying on cerebral blood flow,” Dr. Mathur said. “It's a lot easier to explain this [scan] to a parent than anything else that we do.”
“I must say I find this utterly shocking,” said a member of the audience, who identified himself as a physician from Southampton in the United Kingdom. “We've had a [brain-death] checklist for years.” He said that he was particularly surprised in light of the American reputation for litigiousness.
“I agree that these are shocking data,” Dr. Mathur replied. “However, California law requires in a situation of organ donation that two physicians document that the patient is brain dead. [The law does not] lay out any medical testing or any guidelines or documentation. So if two physicians licensed in the state of California can say a patient is brain dead, that's sufficient. They don't have to specify how they determined it.”
Elements for Brain Death Declaration
In his study, Dr. Mathur and his colleagues examined charts of pediatric organ donors for documentation of the following 14 elements that should be considered before declaring a child to be brain dead, according to 1987 guidelines (Arch. Neurol. 1987;44:587–8):
▸ Documented etiology of coma
▸ Coexistence of coma and apnea
▸ Flaccid tone, no movements
▸ Absence of pupillary reflex
▸ Absence of corneal reflex
▸ Absence of gag reflex
▸ Absence of cough reflex
▸ Absence of eye movement with doll's eye maneuver
▸ Absence of respiratory effort
▸ Absence of hypothermia
▸ Absence of hypotension
▸ Irreversibility of changes
▸ No history of drug or metabolic intoxication
▸ Absence of respiratory effort on apnea test.
Source: Dr. Mathur