DECLARING PEDIATRIC BRAIN-DEATH - CURRENT PRACTICE IN A CANADIAN PEDIATRIC CRITICAL CARE UNIT

Objective: To document the criteria used to declare brain death in a p ediatric critical care unit (PCCU). Design: Retrospective chart review . Setting: Regional PCCU in southwestern Ontario. Patients: Sixty pati ents 16 years of age or less declared brain dead from January 1987 thr ough December 1999. Outcome measures: Presence or absence of documenta tion of irreversible deep coma, nonresponsive cranial nerves, absent b rain-stem reflexes, persistent apnea after removal from ventilator, pr esence or absence of blood flow detected by radioisotope scanning, pre sence or absence of electroencephalographic evidence of electrocerebra l activity. Results: The 60 patients accounted for 1.5% of all PCCU ad missions, 17 were under 1 year of age. In 39 cases brain death was dia gnosed using clinical criteria (''certified brain death''), which coul d not be fully applied in the remaining 21 cases (''uncertifiable but suspected brain death''). Electroencephalography and cerebral blood-fl ow studies with technetium-99m hexamethyl-propyleneamine oxime were us ed as ancillary tests in 16 patients with certified brain death and in 17 with uncertifiable but suspected brain death who survived long eno ugh to be tested. Electrocerebral silence was demonstrated in all nine patients who underwent electroencephalography. Cerebral blood flow wa s undetectable in 26 of the 30 patients tested, and an abnormal patter n of blood flow was seen in the remaining 4, all of whom received a di agnosis of certified brain death. Conclusions: Pediatricians in this l arge tertiary care referral centre are using clinical criteria based o n the 1987 guidelines of the CMA to diagnose brain death in pediatric patients, including neonates. When clinical criteria cannot be fully a pplied, ancillary methods of investigation are consistently used. Alth ough the soundness of this pattern of practice is established for adul ts and older children, its applicability to neonates and infants still needs to be validated.