Seminars in neurology
-
The United Kingdom (UK) has incorporated a brainstem formulation into its brain death criteria since the first guidelines were published in 1976. A clinical diagnosis incorporating three sequential but interdependent steps is sufficient for the determination of brain death in the UK. There must be no doubt that the patient's comatose condition is due to irreversible brain damage of known etiology, and potentially reversible causes of coma and apnea, such as drug effects, metabolic or endocrine disturbances, or hypothermia, must be excluded. ⋯ Confirmatory tests are not required in the UK, but may be useful to reduce any element of uncertainty or minimize the period of observation prior to the diagnosis of brainstem death if the preconditions for clinical testing are not met, or if a comprehensive neurologic examination is not possible. Brainstem death must be diagnosed by two doctors who must be present at each of the two sets of clinical tests that are required to determine death. Although death is not confirmed until the second test has been completed, the legal time of death is when the first test confirms the absence of brainstem reflexes.
-
Asia is the largest and most populous continent in the world with people from many diverse ethnic groups, religions and government systems. The authors surveyed 14 countries accounting for the majority of Asia's population and found that, although the concept of brain death is widely accepted, there is wide variability in the criteria for certification. ⋯ Despite this difference, most countries require only neurologic testing of irreversible coma and absent brainstem reflexes as criteria for certification of brain death. Variability exists in the number of personnel required, qualifications of certifying doctors, need for repeat examination, minimum time interval between examinations, and requirement for and choice of confirmatory tests.
-
Clinical guidelines for the determination of brain death in children were first published in 1987. These guidelines were revised in 2011 under the auspices of the Society of Critical Care Medicine, the American Academy of Pediatrics, and the Child Neurology Society, and provide the minimum standards that must be satisfied before brain death can be declared in infants and children. After achieving physiologic stability and exclusion of confounders, two examinations including apnea testing separated by an observation period (24 hours for term newborns up to 30 days of age, and 12 hours for infants and children from 31 days up to 18 years) are required to establish brain death. ⋯ Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. The committee concluded that ancillary studies may be used (1) when components of the examination or apnea testing cannot be completed, (2) if uncertainty about components of the neurologic examination exists, (3) if a medication effect may be present, or (4) to reduce the interexamination observation period. When ancillary studies are used, a second clinical examination and apnea test should still be performed and components that can be completed must remain consistent with brain death.
-
Skill in the determination of brain death is traditionally acquired during training in an apprenticeship model. Brain death is not frequently determined, and thus exposure to the techniques used is marginal. ⋯ In this review, the authors discuss the advantages and barriers to simulation and how to develop simulation scenarios for instruction in the determination of brain death. Future research should focus on validation of brain death simulation methods and assessment tools as well as the impact of simulation on performance in clinical practice.
-
Despite well-described international variabilities in brain death practices, de facto there already exists a minimum international clinical standard for the diagnosis of brain death. This remains rooted in the Harvard criteria and based on the characteristics of a permanently nonfunctioning brain. Medicine is evolving toward a single unified determination of death based on the cessation of brain function subsequent to catastrophic brain injury or circulatory arrest. ⋯ The cessation of clinical functions of the brain that will not resume is determined by the absence of capacity for consciousness, centrally mediated motor responses, brainstem reflexes, and capacity to breathe. A known proximate cause and the absence of confounding or reversible conditions must be confirmed. Regional medical, legal, cultural, religious, or socioeconomic factors may require testing beyond this minimal clinical standard.