Evidence-based guideline update: Determining brain death in adults Report of the Quality Standards Subcommittee of the American Academy of Neurology

Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA.
Neurology (Impact Factor: 8.29). 06/2010; 74(23):1911-8. DOI: 10.1212/WNL.0b013e3181e242a8
Source: PubMed


To provide an update of the 1995 American Academy of Neurology guideline with regard to the following questions: Are there patients who fulfill the clinical criteria of brain death who recover neurologic function? What is an adequate observation period to ensure that cessation of neurologic function is permanent? Are complex motor movements that falsely suggest retained brain function sometimes observed in brain death? What is the comparative safety of techniques for determining apnea? Are there new ancillary tests that accurately identify patients with brain death?
A systematic literature search was conducted and included a review of MEDLINE and EMBASE from January 1996 to May 2009. Studies were limited to adults.
In adults, there are no published reports of recovery of neurologic function after a diagnosis of brain death using the criteria reviewed in the 1995 American Academy of Neurology practice parameter. Complex-spontaneous motor movements and false-positive triggering of the ventilator may occur in patients who are brain dead. There is insufficient evidence to determine the minimally acceptable observation period to ensure that neurologic functions have ceased irreversibly. Apneic oxygenation diffusion to determine apnea is safe, but there is insufficient evidence to determine the comparative safety of techniques used for apnea testing. There is insufficient evidence to determine if newer ancillary tests accurately confirm the cessation of function of the entire brain.

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    • "Apnea tests remain the gold standard for such determinations. There are special circumstances where confirmatory ancillary tests are used, for example, (a) uncertainty regarding the neurological exam (e.g., patients with unknown/unclear reason for brain death), (b) patients with confounding factors, such as elevated levels of central nervous system sedatives or the presence of residual neuromuscular blockers, (c) incomplete or unreliable neurological exam due to facial trauma or pupillary abnormalities, (d) inability to perform an apnea test due to unstable respiratory or hemodynamic conditions (e.g., high oxygen or vasopressors requirements) [2]. "
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    ABSTRACT: Practice guidelines from the American Academy of Neurology for the determination of brain death in adults define brain death as “the irreversible loss of function of the brain, including the brainstem.” Neurological determination of brain death is primarily based on clinical examination; if clinical criteria are met, a definitive confirmatory test is indicated. The apnea test remains the gold standard for confirmation. In patients with factors that confound the clinical determination or when apnea tests cannot safely be performed, an ancillary test is required to confirm brain death. Confirmatory ancillary tests for brain death include (a) tests of electrical activity (electroencephalography (EEG) and somatosensory evoked potentials) and (b) radiologic examinations of blood flow (contrast angiography, transcranial Doppler ultrasound (TCD), and radionuclide methods). Of these, however, radionuclide studies are used most commonly. Here we present data from two patients with a false positive Radionuclide Cerebral Perfusion Scan (RCPS).
    Full-text · Article · Jul 2015
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    • "Evaluation of the cerebral blood flow is recommended when the results of the ‘apnea test’ are suspected. Prior to the apnea test, it is made sure the patient is normotensive, normothermic, and normocapnic (PaCO2 35mmHg to 45mmHg), with SpO2 less than 95% via mechanical ventilation support with FiO2 at 100% and positive end expiratory pressure (PEEP) at 5cmH2O [28]. An apnea test result is considered as positive if the PaCO2 value increases beyond 60mmHg or more than 20mmHg when the patient is separated from mechanical ventilation for 10 minutes and is given 100% oxygen at 6L/minute rate [28]. "
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    ABSTRACT: Introduction ApneaLink™ (RESMED-Munich, Germany) is a simple and inexpensive device that determines the apnea-hypopnea index. The sensitivity and specificity of the apnea-hypopnea index are 100 and 87.5%, respectively. Our hypothesis can be used to create a treatment plan using the apnea-hypopnea index for intensive care unit patients. Case presentation This treatment plan has been created by determining the apnea-hypopnea index of eight Caucasian patients with a variety of diagnoses. Case 1 is that of a 70-year-old man diagnosed with rectum cancer and scheduled for elective surgery. Case 2 is that of a 65-year-old man diagnosed with rectum cancer and scheduled for elective surgery. Case 3 is that of a 78-year-old woman diagnosed with chronic obstructive pulmonary disease-pneumonia. Case 4 is that of a 26-year-old man diagnosed with head trauma. Case 5 is that of an 80-year-old man diagnosed with cerebrovascular disease. Case 6 is that of a 79-year-old man diagnosed with cerebrovascular disease. Case 7 is that of an 8-year-old girl diagnosed with ventricular septal defect-epidural hemorragia. Case 8 is that of a 42-year-old man diagnosed with subarachnoid hemorrage. Conclusions The apnea-hypopnea index can be informative regarding prognosis and outcomes, and helps to take precautions and develop new treatment strategies among critical patients in intensive care. The integration of developments in sleep medicine to intensive care unit practices means that we can be more informed about critical patients.
    Full-text · Article · Jun 2014 · Journal of Medical Case Reports
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    • "Test needs to be aborted if systolic blood pressure decreases to <90 mm Hg or if patient develops significant arrhythmias or if there is significant oxygen desaturation. After preoxygenating with 100% oxygen for 10 min, it is recommended to insufflate 100% oxygen at 6 L/min through the endotracheal tube, using a catheter, to preserve oxygenation.[2] This method of oxygenation is not free of risk as there are reports of tension pneumothorax leading to cardiac arrest when apnea test was performed.[6] "
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    ABSTRACT: Apnea testing is a key component in the clinical diagnosis of brain death. Patients with poor baseline oxygenation may not tolerate the standard 8-10 min apnea testing with oxygen insufflation through tracheal tube. No studies have assessed the safety and feasibility of other methods of oxygenation during apnea testing in these types of patients. Here, we safely performed apnea testing in a patient with baseline PaO2 of 99.1 mm Hg at 100% oxygen. We used continuous positive airway pressure (CPAP) of 10 cm of H2O and 100% oxygen at the flow rate of 12 L/min using the circle system of anesthesia machine. After 10 min of apnea testing, PaO2 decreased to 75.7 mm Hg. There was a significant rise in PaCO2 and fall in pH, but without hemodynamic instability, arrhythmias, or desaturation. Thus, the apnea test was declared positive. CPAP can be a valuable, feasible and safe means of oxygenation during apnea testing in patients with poor baseline oxygenation, thus avoiding the need for ancillary tests.
    Full-text · Article · May 2014 · Indian Journal of Critical Care Medicine
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