P2A290: Variation in Regional Pediatric Brain Death Policies

Background: Approximately 20% of pediatric deaths in pediatric intensive care units (PICU) in the United States are declared as death by neurological criteria (DNC), defined as the irreversible cessation of clinical brain function. A review of adult brain death (BD) policies demonstrated wide variability and many policies were incongruent with contemporary practice parameters. Even though expert guidelines for DNC in children exist, variability in hospital policies for pediatric DNC continue to persist.

Methods: Sixteen pediatric BD policies from referral hospitals under a single organ procurement organization (OPO) were collected and analyzed. Referral center characteristics such as status as a stand-alone children’s hospital versus pediatric unit, presence of pediatric and neonatal intensive care units, and presence of pediatric-trained intensivists/neurologists/neurosurgeons were captured. Policies were evaluated across four categories: (1) clinical prerequisites for brain death testing, (2) components of the clinical exam, (3) apnea testing, and (4) ancillary testing. It was also noted if a separate pediatric policy existed and whether the last update was consistent with either pediatric guidelines by Nakagawa, et al. (2011) or the World Brain Death Project guidelines (2020).

Results: Of the sixteen hospitals, one was a stand-alone children’s hospital and twelve had pediatric-specific units. Nine centers had dedicated PICUs. Eight and five centers had pediatric neurologists and neurosurgeons respectively. Notably, only six (38%) hospitals had separate pediatric BD policies. The remaining ten either had a section within their adult guidelines specifying differences in pediatrics or did not have a pediatric-specific section, utilizing the adult BD checklist with few optional points for pediatric-specific details. Only five (31%) policies were updated 2020 and beyond, meaning most policies were not up to date with the current World Brain Death guidelines. Twelve (75%) policies required two separate clinical exams, with eleven (69%) specifying age dependent distinction in timing between two exams. Variability was noted in the clinical prerequisites for brain death testing, namely waiting 24 hours after cardiac arrest (44%), maintenance of core body temperature of equal or greater than 36 degrees for 24 hours (56%), need for normotension based on age-specific guidelines (31%), and ensuring five elimination half lives of all sedatives and anesthetics have passed (19%). Only nine (56%) policies mentioned which providers (e.g., level of training and specialty) could perform the apnea test . Variability was noted in required criteria for apnea test, namely - four policies did not require both pCO2 >60 mmHg AND >20 mmHg rise from baseline. Most policies named the radionuclide cerebral blood flow study and electroencephalography (EEG) as acceptable ancillary tests.

Conclusion: If available, pediatric-specific BD policies were widely variable and incongruent with the current practice standard. Streamlining institutional policies to align with these international guidelines may lead to improved consistency in declaring pediatric death by neurologic criteria.