New Brain Death Guidelines Issued

From Medscape Medical News

Allison Gandey

June 10, 2010 — The American Academy of Neurology has released new guidelines for determining brain death in adults. Updated for the first time in 15 years, the recommendations provide step-by-step instructions to help guide clinical decision making.

"The brain death diagnosis can be made only after a comprehensive clinical evaluation and often involves more than 25 separate assessments," lead author Eelco Wijdicks, MD, from the Mayo Clinic in Rochester, Minnesota, said in a news release.

The guidelines are published in the June 8 issue of Neurology.

The authors report that new data have confirmed the effectiveness of earlier recommendations. They saw no evidence of recovery of neurologic function after a diagnosis of brain death using the criteria from the 1995 practice parameter.

Checklist for determining brain death.

"To correctly diagnose brain death, it is essential clinicians adhere to a uniform framework," coauthor Gary Gronseth, MD, from the University of Kansas, Kansas City, said in an interview.

"We wanted to provide useful tools to help clinicians," Dr. Gronseth said, "but many factors will still need to be based on clinical judgment."

The authors report insufficient evidence to determine the minimally acceptable observation period to ensure that neurologic functions have ceased irreversibly.

"I think some people will be disappointed that we weren't able to nail this down," Dr. Gronseth said, "but this will be highly variable patient to patient, and there is no general rule."

These new guidelines focus on patients 18 years and older. Another group is currently working on new brain death recommendations for children. Those recommendations are expected to be released in a couple of months. Some predict those guidelines will include a prescribed observation period.

"Different groups take different approaches," Dr. Gronseth noted. "We felt the evidence was lacking."

Single Exam Sufficient

Some clinicians may also be surprised to see that more than 1 exam is not required in the new brain death guidelines. "The original guideline did not require this either, but I think it was a common misconception that 2 exams are necessary. This is not the case," Dr. Gronseth said. "Some people may object, but we found that 1 exam was sufficient."

The authors point out that complex-spontaneous motor movements and false-positive triggering of the ventilator may occur in patients who are brain dead.

Oxygenation diffusion to determine apnea is safe, they report, but there is insufficient evidence to determine the comparative benefit of the various techniques used for apnea testing.

There is also insufficient evidence to determine whether newer ancillary tests accurately confirm the cessation of function of the entire brain.

To correctly diagnose brain death, it is essential clinicians adhere to a uniform framework.
Asked by Medscape Neurology to comment on the new guidelines, James Bernat, MD, from Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, said he hopes these recommendations will help address the often wide variation among hospitals.

In 2008, guideline senior author David Greer, MD, from Massachusetts General Hospital, in Boston, reported substantial differences in approaches to brain death among leading neurological institutions in the United States.

That study, published in Neurology, prompted this guideline update because the authors felt more detail was needed to help physicians (2008;70;284-289).

"The new recommendations are encouraging uniformity and thoroughness among institutions," Dr. Bernat said.

"Moving forward, I'd like to see a national registry to track brain death, so we can get an idea of how we're doing," Dr. Gronseth said. "This registry should be voluntary. A lot of studies are done this way."

The American Academy of Neurology will be hosting an online conference about the new guidelines Monday, June 21. The authors will present at the session and take questions. The registration deadline for continuing medical education credit is June 16. Clinicians wanting to participate will need a computer with Microsoft Office Powerpoint and a telephone. For more information and to access the audio conference, visit the academy's Web site.

Neurology. 2010;74:1911-1918. Abstract