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cover of episode SCCM Pod-533 CCM: Updated Brain Death Guidance: What Critical Care Teams Need to Know

SCCM Pod-533 CCM: Updated Brain Death Guidance: What Critical Care Teams Need to Know

2025/1/9
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Matthew Kirshen, MD, PhD
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Matthew Kirshen, MD, PhD: 更新后的脑死亡指南整合了成人和儿童的标准，并得到了多个相关专业组织的共同认可，确保了脑死亡判定的准确性和一致性。指南中脑死亡的基本定义没有改变，仍然需要满足灾难性脑损伤、永久性损伤、昏迷和无反应、脑干反射消失以及在排除相关混杂因素后无法自主呼吸等条件。此外，指南增加了针对特殊情况的建议，例如孕妇、使用VA-ECMO和VV-ECMO患者以及原发性幕下病变患者的脑死亡评估。对于儿童，脑死亡的基本标准与十年前的指南相比没有改变，但对神经系统检查的说明更加清晰。儿童脑死亡评估需要进行两次神经系统检查和两次呼吸暂停试验，两次检查之间的时间间隔至少为12小时。成人脑死亡评估需要进行一次神经系统检查和一次呼吸暂停试验，建议进行第二次检查以降低误诊的可能性。目前缺乏数据支持儿童脑死亡评估需要两次检查而成人只需要一次检查的结论。进行第二次独立的脑死亡评估可以提高诊断的准确性，降低误诊的可能性。进行脑死亡评估的医务人员应该接受充分的培训，并具备进行评估的能力。美国脑死亡的法律依据是《统一死亡判定法案》(UDDA)，该法案规定脑死亡的判定应符合公认的医学标准。2023年多专业协会指南被认为是公认的医学标准，基于全脑死亡的概念。对于原发性幕下损伤患者，只有当损伤继发导致大脑皮质损伤时才能进行脑死亡评估。进行脑死亡评估不需要获得家属的同意，但有义务告知家属将进行评估。虽然呼吸暂停试验存在风险，但可以通过遵循标准流程和设定停止规则来降低风险。在满足特定条件下进行呼吸暂停试验是安全的。研究表明，在呼吸暂停试验期间，颅内压升高不会导致脑损伤加重。在患者不耐受呼吸暂停试验或风险过高的情况下，可以使用辅助检查。可用于脑死亡评估的辅助检查包括四血管常规血管造影、核医学脑血流和灌注研究以及经颅多普勒超声。脑电图已被移除作为脑死亡评估的辅助检查方法。只有在无法完全评估脑干功能或存在无法解决的混杂因素时才应使用辅助检查。只有在能够进行的神经系统检查结果均与脑死亡一致的情况下，才应进行辅助检查。辅助检查应作为脑死亡评估过程中的最后一步。医疗机构应更新其机构规程，以符合更新后的脑死亡判定指南，并确保医务人员接受充分的培训。在脑死亡评估中，使用核对表至关重要。在脑死亡评估过程中，如果存在任何不确定性，应寻求帮助。 Diane McLaughlin: 作为主持人，Diane McLaughlin 负责引导访谈，提出问题，并对 Matthew Kirshen, MD, PhD 的观点进行总结和补充。她强调了指南更新的重要性以及在实践中正确应用指南的必要性。

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This chapter explores the collaboration between numerous organizations like the American Academy of Neurology, American Academy of Pediatrics, and the Society of Critical Care Medicine in updating brain death determination guidelines. It highlights the importance of consensus and the shared mission to improve the accuracy of brain death determination.
  • Collaboration between multiple organizations (American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and SCCM) to update brain death guidelines.
  • Goal was to create guidelines applicable to both adults and children.
  • Challenges included aligning the interests of different organizations but the shared mission facilitated agreement.

Shownotes Transcript

Host Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, welcomes Matthew Kirschen, MD, PhD, FAAN, FNCS, to discuss what critical care professionals need to know about determining brain death/death by neurologic criteria (BD/DNC).

In October 2023, a revised consensus practice guideline for the determination of brain death in both children and adults was published in Neurology (Greer DM, et al. Neurology. 2023;101;1112-1132)). The guideline integrated guidance for adults and children to provide a comprehensive, practical way to evaluate patients with catastrophic brain injuries to determine whether they meet the criteria for brain death.

The Society of Critical Care Medicine (SCCM) offers several additional resources to support critical care clinicians’ understanding of the updated guidelines, including an article published in the March 2024 issue of Critical Care Medicine addressing what the critical care team needs to know about the guidelines (Kirschen MP, et al. Crit Care Med. 2024;52:376-386)). Dr. Kirchen was the lead author of that article and shares key points in this podcast episode.

Other resources include:

  • Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guidelines) 2024 Critical Care Congress presentation

  • Free AAN evaluation tool) that walks clinicians through the process of brain death evaluation.

  • Special article in Neurology: Clinical Practice that provides a detailed narrative about what has changed in the 2023 guidelines compared to prior guidelines). The article also includes tables outlining comparisons, bolding new recommendations, and italicizing age-specific guidance to easily identify the differences between determining brain death in children versus adults.