Francoeur Conall, Weiss Matthew J, MacDonald Jennifer M, Press Craig, Greer David M, Berg Robert A, Topjian Alexis A, Morrison Wynne, Kirschen Matthew P
From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania.
Neurology. 2021 Jul 19;97(3):e310-e319. doi: 10.1212/WNL.0000000000012225.
To determine the variability in pediatric death by neurologic criteria (DNC) protocols between US pediatric institutions and compared to the 2011 DNC guidelines.
In this cross-sectional study of DNC protocols obtained from pediatric institutions in the United States via regional organ procurement organizations, protocols were evaluated across 5 domains: general DNC procedures, prerequisites, neurologic examination, apnea testing, and ancillary testing. Descriptive statistics compared protocols to each other and the 2011 guidelines.
A total of 130 protocols were analyzed with 118 dated after publication of the 2011 guidelines. Of those 118 protocols, identification of a mechanism of irreversible brain injury was required in 97%, while 67% required an observation period after acute brain injury before DNC evaluation. Most protocols required guideline-based prerequisites such as exclusion of hypotension (94%), hypothermia (97%), and metabolic derangements (92%). On neurologic examination, 91% required a lack of responsiveness, 93% no response to noxious stimuli, and 99% loss of brainstem reflexes. A total of 84% of protocols required the guideline-recommended 2 apnea tests. CO targets were consistent with guidelines in 64%. Contrary to guidelines, 15% required ancillary testing for all patients and 15% permitted ancillary studies that are not validated in pediatrics.
Variability exists between pediatric institutional DNC protocols in all domains of DNC determination, especially with respect to apnea and ancillary testing. Better alignment of DNC protocols with national guidelines may improve the consistency and accuracy of DNC determination.
确定美国儿科机构间基于神经学标准的儿科死亡（DNC）方案的差异，并与2011年DNC指南进行比较。
在这项横断面研究中，通过区域器官采购组织从美国儿科机构获取DNC方案，对方案在5个领域进行评估：一般DNC程序、先决条件、神经学检查、呼吸暂停测试和辅助测试。描述性统计将各方案相互比较，并与2011年指南进行比较。
共分析了130个方案，其中118个方案的日期在2011年指南发布之后。在这118个方案中，97%要求确定不可逆脑损伤机制，而67%要求在急性脑损伤后有一个观察期才能进行DNC评估。大多数方案要求基于指南的先决条件，如排除低血压（94%）、体温过低（97%）和代谢紊乱（92%）。在神经学检查方面，91%要求无反应性，93%要求对有害刺激无反应，99%要求脑干反射消失。共有84%的方案要求进行指南推荐的2次呼吸暂停测试。64%的方案中二氧化碳目标与指南一致。与指南相反，15%要求对所有患者进行辅助测试，15%允许进行在儿科未经验证的辅助研究。
儿科机构DNC方案在DNC判定的所有领域均存在差异，尤其是在呼吸暂停和辅助测试方面。使DNC方案更好地与国家指南保持一致，可能会提高DNC判定的一致性和准确性。
