Lightning rounds #35: Brain death updates, with Ariane Lewis and Matthew Kirschen

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Discussing the new 2023 AAN/AAP/CNS/SCCM Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline, with the joint first authors: Dr. Ariane Lewis, neurointensivist, professor of neurology and neurosurgery at NYU Langone, director of neurocritical care, and chair of the Langone ethics committee, and Dr. Matthew Kirschen, pediatric neurointensivist and associate director of pediatric neurocritical care at the Children’s Hospital of Philadelphia.

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Takeaway lessons

1. Ancillary testing (the idea of “confirmatory” testing is not optimal) is not a replacement for the clinical exam, and any confounding factors to the exam that can be corrected (for example, by waiting longer for temperature or drugs to normalize) must be—this cannot be bypassed by skipping to an ancillary test.
2. Drug levels that may confound the exam should be measured whenever possible, and when there is doubt or question, the monitoring period should be increased, even if this delays the time until declaration of death.
3. Drug use that results in clear anoxic brain injury can be compatible with declaring brain death based on the later, even if the exact nature of the former is not established.
4. Temperature must be above 36c during the exam, and above 35.5c for the last 24 hours.
5. Brain death testing in the setting of anoxia after cardiac arrest should be delayed for at least 24 hours after arrest.
6. A minimum of one clinical exam should be performed in adults, but one or more additional exams may be useful. A minimum of two are recommended in pediatrics. Local protocol should be followed. No specific interval of waiting between exams is recommended in adults (the important “waiting” should occur prior to performing the first exam), although a 12-hour minimum interval in pediatrics is recommended, mainly for historical reasons.
7. Advanced practice providers may perform the exam if appropriately trained and credentialed.
8. EEG is not recommended as an ancillary test, mainly because it primarily gives information on cortical electrical activity, which adds relatively little to a confounded clinical examination. Bloodflow tests like nuclear scintigraphy say something about perfusion to the brain (particularly when a lateral view is used), which is useful.
9. Brain death testing must be done 100% right, 100% of the time. All providers should follow hospital policy and state law, not just guidelines when there is conflict. Ideally the two will match, but this can take time to catch up when new guidelines are released.