Variability in brain death determination practices in children

Abstract

Objective: To investigate variability in practices for determining brain death and organ procurement results in pediatric intensive care units (PICUs).

Design: Prospective cohort study.

Setting: Pediatric ICUs.

Patients: Children undergoing brain death evaluations selected from 5415 consecutive PICU admissions.

Main outcome measures: Data from children undergoing brain death evaluations including number of coma examinations, number and duration of apnea tests, PCO2 measurements at the end of the apnea test, ancillary tests used to confirm brain death, organ procurement, and reasons for nonprocurement.

Results: A total of 93 (37%) of 248 deaths were brain deaths. Compared with the other deaths, children who were classified as brain dead were sicker on admission (mean Pediatric Risk of Mortality [PRISM] score +/- SD: 31 +/- 11 vs 23 +/- 12, P < .001; pre-ICU cardiopulmonary resuscitation: 72% vs 40%, P < .001), and had more traumatic injuries (42% vs 12%, P < .001). Variability in apnea testing included lack of apnea testing in 23 patients (25%) and controversial apnea testing practices in 20 patients (22%). Three patients (3%) had brain death evaluations within hours of discontinuing barbiturate infusions, and four of 30 patients younger than 1 year did not have a confirmatory test. Solid organ procurement was successful in 32%. Reasons for nonprocurement included parental refusal (12%), disease state (12%), and medical examiner's case (22%).

Conclusions: Substantial variability exists in the criteria used by clinicians for the diagnosis of brain death. Some practices are contradictory to the Guidelines for the Determination of Brain Death in Children and to recommendations for apnea testing. Organ procurement could be improved by increased medical examiner cooperation.