DETERMINATION OF BRAIN DEATH IN CHILDREN IN TAIWAN

Objectives: In Taiwan, the guideline for determination of brain death was first established in 1987, and revised in 2004. In the revised guideline, children under 3 years of age were excluded. Facing the fact that there has been increasing demand for the establishment of criteria for diagnosis of brain death in young children, we conducted a national survey of the clinical practice of brain death determination on children younger than 18 years old, that we expected may allow us to develop criteria for the diagnosis of brain death in children younger than 3 years old. Methods: The subjects of the survey included infants and children younger than 18 years old, who were diagnosed to be either brain-dead or near-brain-dead according to the guidelines for the determination of brain death in children in Taiwan from 15 teaching hospitals that were considered to encounter pediatric brain death during the period from April 1988 to January 2005. Results: Fifty-six children (41 males, 15 females) were enrolled. The average age of children diagnosed as brain death was 8 years and 8 months old (1 month to 18 years, median age: 8 years). Twenty children (36%) aged less than 3 years. Twenty-four patients (43%) suffered head injury which was the most frequent cause of brain damage. Since the apnea test is of great importance in the diagnosis of brain death, cases for which strictly 2 or more sessions of the apnea test were conducted were classified into Group I. Cases for which at least one session of neurological testing was performed, but in whom the apnea test was performed only once, were classified into Group II. Cases in whom brain death was diagnosed without the apnea test were classified into Group III (2 or more sessions of neurological testing) or Group IV (only one session of neurological testing). The apnea test was positive in all of the tested cases in whom arterial blood gas was performed. At the first examination in Group I, the mean PaCO2 was 49.0±10.6mmHg before the test, and 80.3±15.9mmHg at the end of the test. At the second examination in Group I, the mean PaCO2 was 47.7±8.9mmHg before the test, and 79.4±16.5mmHg at the end of the test. In Group II, the mean PaCO2 was 44.5±29.9mmHg before the test, and 92.0±32.7mmHg at the end of the test. The average observation period to perform the brain death test was 169 hours, ranging from 12 hours to 1416 hours, with median observation period of 76 hours. In the present study, all the cases eventually developed cardiac arrest without any survival. Fifteen (27%) children suspected brain-death or near-brain-death died spontaneously from cardiopulmonary arrest within 62 days. The mean duration between the diagnosis of brain death and the development of cardiac arrest was 18 days, ranging from 1 day to 62 days. Thirty-six (64%) children fulfilled the criteria for the determination of brain death in children, and brain death was declared after two apnea tests were performed successfully at least 4 hours apart. Solid organ procurement or tissue graft was successful in 41 children (73%).

Conclusion: The current guideline for determination of brain death in children seems adequate for children older than 3 year old in Taiwan. A longer observation period for children younger than 3 years old, especially those cases with hypoxic ischemic encephalopathy, may be indicated. Further prospective studies, such as using confirmatory tests for the diagnosis of brain death, especially in children younger than 3 years old, may be needed.