Thank you very much, and thank you for the opportunity to speak today. Here are my disclosures. I have funding which is unrelated to brain death, and you will hear from many of us up here that we do a lot of work for multiple organizations on brain death, but we have no financial stake in its determination. So this is pretty much the outline for the next hour. We are going to talk about the recent consensus guideline that was published. This was a collaborative effort between the American Academy of Neurology, Society of Critical Care Medicine, American Academy of Pediatrics, and the Child Neurology Society. There's a QR code at the bottom that I'll leave the slide up for another second. If you have not seen this document yet, you can click on that QR code, and it will link you to the neurology.org website where you can download for free the actual guideline itself. So one of the big questions we always get asked is, well, why do this guideline, right? Death hasn't changed in the past 10 years, but some of the evidence may have. So the adult and the pediatric guidelines were each published more than 10 years ago, and so we wanted to use this opportunity to review data that was available. And we also wanted to acknowledge the fact that death should really be independent of age. And so because of that, we wanted to combine the adult and the pediatric guidelines into a single document, and we also recognized that medical technology has advanced over the past 10 years, and so we wanted to address medical areas that impacted brain death, such as ECMO, therapeutic hypothermia, therapies to treat ICP, pregnancy, and primary infant tentorial injury that were not addressed in either of the two prior guidelines. It will come as no surprise to the people in this room that we don't have a lot of data in the brain death space. When we talk about guidelines, we are not going to have big randomized controlled trials and do typical grade methodology in terms of designing guidelines for brain death as we do for other diseases within our space. And so this is really an evidence-informed process. We use Delphi methodology. And as you look at the document, you will notice that recommendations have three different anchoring verbs. There are musts, shoulds, and mays, and then levels of strength that go with each one of those recommendations. And those fell out of voting from the guideline committee. Let's talk just a little bit about terminology. So we decided to use the hyphenated term brain death, death by neurologic criteria, and we did that in deference to the colloquial term brain death, but also to reinforce that it is not just death of the brain. It is death of the entire person, and it is medically and legally equivalent to cardiopulmonary death. We define children as individuals less than 18 years old. And the panel chose to use the word permanent to describe the extent of the loss of brain function that must be present in an individual in order to determine brain death. And we use permanent. And the definition that we use, as we said, permanent means that function was lost, and it will not resume spontaneously, and that medical interventions will not be used to attempt to restore any brain function. Even though it has been 10 years since the last iteration of the guidelines, I think it's important to point out that the fundamental definition of brain death has not changed. It still requires you to have a catastrophic brain injury. The patient has to be observed for a period of time to ensure the brain injury is permanent. And then on a clinical evaluation, you need to demonstrate no evidence of brain function by demonstrating the patient's comatose, has brainstem areflexia, and the absence of respiratory drive with inadequate stimulus. The guideline has 85 recommendations. We are clearly not going to be able to go through all of them today, but we're going to hit a few of the highlights. I'm going to focus first on the key concepts we have to use when talking about approaching a patient that you are suspicious for brain death. Our intent here in these recommendations was to be conservative. We wanted to really minimize the risk of a false positive determination, but at the same time make sure that the recommendations were practical so that they could be implemented in any of our ICUs across the country. While you have a suspicion that the patient will meet criteria for brain death, the presumption is that the patient does not meet brain death criteria, and your goal when walking into that room is to disprove that presumption. What this does is this takes our bias from going into the room to prove the patient's dead versus going into the room to say, I'm going to do the most standardized, protocolized, comprehensive neurologic assessment that we know how to do in order to look for any evidence of brain function. And if we do not find any evidence of brain function, then it means the patient meets criteria for death. It is important within this space that we need to provide support and guidance for families as they face these difficult end-of-life decisions. Our communication needs to be clear, concise, and supportive by using simple terminology that our families can understand. And it may be helpful for us to provide the opportunity for families to observe the evaluation, including the clinical exam and the apnea test, and it may help them come to terms with the gravity and the irreversibility of the brain injury and the situation. Who is a qualified examiner? It must be an attending physician, and that attending physician must be adequately trained and competent in the brain death evaluation. That competence can be achieved by a supervised evaluation in a clinical setting, and there's in-person and online courses which can help supplement that. Trainees must be directly supervised. In most situations, APPs should also be directly supervised. However, there are some states where APPs are allowed to do brain death evaluations independently, and if it is allowed in your state and per your institutional policy and guidelines, then that is permissible. The last thing I'm going to talk about are the prerequisites, and I think that this is probably the most important part. Don't tell Dave and Ariane that we're coming next, but probably the most important part of the brain death evaluation process, and in many of the cases where people have woken up from brain death, it is because the prerequisites were not meticulously evaluated. So we must know the mechanism of the brain injury. You have to know that they've sustained a catastrophic permanent brain injury, and you've got to know the mechanism of injury. Typically, that's trauma, hypoxemic brain injury from cardiac arrest, intracranial hemorrhage, et cetera. If you have a patient who is comatose with no brain stem reflexes on their exam and you do not know the mechanism of the brain injury, you must do further diagnostic testing in order to figure out the cause of the injury prior to proceeding with the evaluation. Neuroimaging is not required, although it is performed in most cases, and if you do have neuroimaging, it should be consistent with the mechanism and the severity of the injury. There is a lot of discussion around the amount of time that you need to observe somebody after the injury has occurred before we feel confident saying that the injury is irreversible or permanent and that it is okay to proceed with the evaluation. Now, we do not have great data on how long that observation period should be. However, we do feel strongly that it should be based on the pathophysiology of the brain injury leading to the clinical state of the patient. In patients less than two years old, it is recommended that you observe the patient for at least 48 hours prior to proceeding with the evaluation, and that has to do with the fact that infants have open fontanelles and unfused sutures and may not experience the same sequelae of refractory intracranial hypertension as somebody with an intact calvarium, and also because the brainstem in young infants is more resistant to hypoxic ischemic injury, which is the predominant mechanism in that age group. If you are older than two years old, after hypoxic ischemic brain injury in particular, we recommend waiting 24 hours. The last point I'll measure here is if you do some sort of intervention for neuroprotection or neuroresuscitation, say doing something to decrease your intracranial pressure, it is important to then give a sufficient amount of time to see whether that intervention worked prior to saying that the brain injury is permanent. So if you put in an EVD, if you do a hemicraniectomy, if you give hyperosmolar therapy, give an appropriate amount of time to see whether your interventions worked prior to saying the injury is permanent. The last thing, and this is maybe the most important slide that I have up here, is that is you need to exclude confounding factors. There's toxins and medications that can impact the ability for you to interpret your neurologic exam. If you're hypothermic, that can impact your ability to interpret your exam. The same with hypotension and metabolic factors. We do not have time today to go through all of these in great detail, but please make sure that medications are adequately cleared out of the system. Your core body temperature is greater than 36 degrees. You are normotensive for age, and metabolic factors have been excluded. There are comprehensive tables in the appendices of the guidelines that go through recommended goal ranges for the metabolic laboratory values, as well as medication data and metabolism and clearance of those medications that is broken down by age group and has additional commentary if you have hepatic or renal failure. And there's a QR code there if you want direct access to those tables. So in summary from this first part, be knowledgeable and be prepared. Please review the updated guidelines. We've talked about the general principles and the prerequisites, and Dr. Greer is now going to talk about the exam and the apnea test. Remember to meticulously review prerequisite and confounding conditions. And when in doubt, please stop and ask for help. Brain death is one of the few domains in medicine where we've got to be 100% right 100% of the time. Thank you very much. Thank you.

brain death guidelines

medical collaboration

adult and pediatric criteria

evaluation standardization

confounding factors