TY - JOUR
T1 - Determination of Brain Death/Death by Neurologic Criteria
T2 - The World Brain Death Project
AU - Greer, David M.
AU - Shemie, Sam D.
AU - Lewis, Ariane
AU - Torrance, Sylvia
AU - Varelas, Panayiotis
AU - Goldenberg, Fernando D.
AU - Bernat, James L.
AU - Souter, Michael
AU - Topcuoglu, Mehmet Akif
AU - Alexandrov, Anne W.
AU - Baldisseri, Marie
AU - Bleck, Thomas
AU - Citerio, Giuseppe
AU - Dawson, Rosanne
AU - Hoppe, Arnold
AU - Jacobe, Stephen
AU - Manara, Alex
AU - Nakagawa, Thomas A.
AU - Pope, Thaddeus Mason
AU - Silvester, William
AU - Thomson, David
AU - Al Rahma, Hussain
AU - Badenes, Rafael
AU - Baker, Andrew J.
AU - Cerny, Vladimir
AU - Chang, Cherylee
AU - Chang, Tiffany R.
AU - Gnedovskaya, Elena
AU - Han, Moon Ku
AU - Honeybul, Stephen
AU - Jimenez, Edgar
AU - Kuroda, Yasuhiro
AU - Liu, Gang
AU - Mallick, Uzzwal Kumar
AU - Marquevich, Victoria
AU - Mejia-Mantilla, Jorge
AU - Piradov, Michael
AU - Quayyum, Sarah
AU - Shrestha, Gentle Sunder
AU - Su, Ying Ying
AU - Timmons, Shelly D.
AU - Teitelbaum, Jeanne
AU - Videtta, Walter
AU - Zirpe, Kapil
AU - Sung, Gene
N1 - Funding Information:
reported being the medical advisor for deceased donation at Canadian Blood Services, a government-funded nonprofit organization tasked with producing clinical practice guidelines for death determination and organ donation in Canada. Dr Varelas reported receiving a grant from the Gift of Life of Michigan Foundation for Brain Death Simulation courses. Dr Souter reported receiving funding from Lifecenter Northwest outside the submitted work. Dr Nakagawa reported receiving royalties from Wolters Kluwer and UpToDate. Dr Timmons reported current and past leadership positions in several neurosurgical societies/ organizations, including the American Association of Neurological Surgeons (AANS) and the Joint Section of Neurotrauma and Critical Care of the AANS and Congress of Neurological Surgeons. She did not participate in these organizations' review of the manuscript for endorsement of educational content, as part of our normal recusal processes. Authors are debarred from participating in reviews. No other disclosures were reported.
PY - 2020/9/15
Y1 - 2020/9/15
N2 - Importance: There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. Objective: To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. Process: Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. Evidence Synthesis: Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. Recommendations: Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability. Conclusions and Relevance: This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries..
AB - Importance: There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. Objective: To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. Process: Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. Evidence Synthesis: Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. Recommendations: Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability. Conclusions and Relevance: This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries..
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U2 - 10.1001/jama.2020.11586
DO - 10.1001/jama.2020.11586
M3 - Review article
C2 - 32761206
AN - SCOPUS:85089152867
VL - 324
SP - 1078
EP - 1097
JO - JAMA - Journal of the American Medical Association
JF - JAMA - Journal of the American Medical Association
SN - 0098-7484
IS - 11
ER -