Variability of brain death determination guidelines in leading US neurologic institutions
CalixtoMachado, AAN Corresponding Fellow, Institute of Neurology and Neurosurgery, 29 y D, Vedado, La Habana 10400, Cuba[email protected]
Submitted February 14, 2008
Greer et al. reported major differences in brain death (BD) guidelines in US hospitals. [1] Wijdicks published relevant worldwide differences on BD determination. [2] Although I expected those results from the Wijdicks’ article, this paper surprised me considering the AAN practice parameters for determining BD established in 1995.
Most countries and states do not present an ordered formulation of three distinct elements: the definition of death, the anatomic-physiologic substratum (criterion), and the tests (clinical and ancillary) to confirm that the criterion has been satisfied. For example, the Commonwealth countries defend a brainstem standard of BD; meanwhile the Uniform Determination of Death Act in the United States demands proof of irreversible cessation of function of the whole brain. [3]
It is surprising that most institutions do not require a specific area of expertise in physicians involved in BD diagnosis which requires training. In Cuba, neurologists and neurosurgeons are mainly involved, although intensivists with previous training also participate.
Individual prerequisites vary: ensuring the absence of sedatives/paralytics, acid-base disorders, endocrine disorders, hypothermia or shock. These circumstances can mimic BD without being irreversible. Moreover, BD etiology has not always excluded possible causes of reversible coma. Apnea testing showed several variations.
Wijdicks also demonstrated differences among countries. [2] The use of transcranial Doppler (TCD) was only recommended in 42% of centers despite the AAN Therapeutics and Technology Assessment Subcommittee report, affirming that the TCD sensitivity and specificity for detecting circulatory arrest were 91-100 and 97-100%, respectively. [4]
In Cuba, we have proposed using confirmatory tests to prove absent cerebral blood flow (CBF) and to demonstrate loss of bioelectric activity. These tests should be used when clinical examination is not reliable, to shorten period of observation, and in primary brainstem lesions. Among those tests to detect absent CBF, we defended the use of TCD, and a neurophysiologic test battery (multimodality evoked potentials and electroretinography) to show loss of bioelectric activity. [5]
Considering the variability of BD guidelines in the US [1] and the rest of the world, [2] I agree with the authors that the AAN Guidelines should be reviewed, including this diagnosis in children. Furthermore, the World Federation of Neurology should also organize a Committee for reviewing and standardizing guidelines for worldwide consensus in BD diagnostic criteria.
References
1.Greer DM, Varelas PN, Haque S, Wijdicks EFM. Variability of brain death determination guidelines in leading US neurologic institutions. Neurology 2008;70:1–1.
2.Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria. Neurology 2002;58:20-25.
3.Machado C, ed. Brain Death: A Reappraisal. New York: Springer 2007:1-223.
4.Sloan MA, Alexandrov AV, Tegeler CH, et al. Assessment: Transcranial Doppler ultrasonography: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2004; 62:1468-1481.
5.Machado C, Abeledo M, Álvarez C, et al. Cuba has passed a law for the determination and certification of death. Adv Exp Med Biol. 2004; 550:139-142.
Disclosure: The author reports no conflicts of interest.
Greer et al. reported major differences in brain death (BD) guidelines in US hospitals. [1] Wijdicks published relevant worldwide differences on BD determination. [2] Although I expected those results from the Wijdicks’ article, this paper surprised me considering the AAN practice parameters for determining BD established in 1995.
Most countries and states do not present an ordered formulation of three distinct elements: the definition of death, the anatomic-physiologic substratum (criterion), and the tests (clinical and ancillary) to confirm that the criterion has been satisfied. For example, the Commonwealth countries defend a brainstem standard of BD; meanwhile the Uniform Determination of Death Act in the United States demands proof of irreversible cessation of function of the whole brain. [3]
It is surprising that most institutions do not require a specific area of expertise in physicians involved in BD diagnosis which requires training. In Cuba, neurologists and neurosurgeons are mainly involved, although intensivists with previous training also participate.
Individual prerequisites vary: ensuring the absence of sedatives/paralytics, acid-base disorders, endocrine disorders, hypothermia or shock. These circumstances can mimic BD without being irreversible. Moreover, BD etiology has not always excluded possible causes of reversible coma. Apnea testing showed several variations.
Wijdicks also demonstrated differences among countries. [2] The use of transcranial Doppler (TCD) was only recommended in 42% of centers despite the AAN Therapeutics and Technology Assessment Subcommittee report, affirming that the TCD sensitivity and specificity for detecting circulatory arrest were 91-100 and 97-100%, respectively. [4]
In Cuba, we have proposed using confirmatory tests to prove absent cerebral blood flow (CBF) and to demonstrate loss of bioelectric activity. These tests should be used when clinical examination is not reliable, to shorten period of observation, and in primary brainstem lesions. Among those tests to detect absent CBF, we defended the use of TCD, and a neurophysiologic test battery (multimodality evoked potentials and electroretinography) to show loss of bioelectric activity. [5]
Considering the variability of BD guidelines in the US [1] and the rest of the world, [2] I agree with the authors that the AAN Guidelines should be reviewed, including this diagnosis in children. Furthermore, the World Federation of Neurology should also organize a Committee for reviewing and standardizing guidelines for worldwide consensus in BD diagnostic criteria.
References
1.Greer DM, Varelas PN, Haque S, Wijdicks EFM. Variability of brain death determination guidelines in leading US neurologic institutions. Neurology 2008;70:1–1.
2.Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria. Neurology 2002;58:20-25.
3.Machado C, ed. Brain Death: A Reappraisal. New York: Springer 2007:1-223.
4.Sloan MA, Alexandrov AV, Tegeler CH, et al. Assessment: Transcranial Doppler ultrasonography: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2004; 62:1468-1481.
5.Machado C, Abeledo M, Álvarez C, et al. Cuba has passed a law for the determination and certification of death. Adv Exp Med Biol. 2004; 550:139-142.
Disclosure: The author reports no conflicts of interest.