Pediatric and Adult Brain Death/Death by Neurologic Criteria
General Principles for the BD/DNC Evaluation
Clinicians Who Perform BD/DNC Evaluations
Prerequisites for Determination of BD/DNC
Identification of the Etiology of Brain Injury
Observation for Permanency
Avoiding Inaccurate Determination of BD/DNC Caused by Hypothermia
Avoiding Inaccurate Determination of BD/DNC Caused by Hypotension
Avoiding Inaccurate Determination of BD/DNC Caused by Drugs/Medications and Metabolic Derangements
- Ensure a toxicology (urine and blood) screening result, if clinically indicated, is negative.
- Ensure the alcohol blood level, if clinically indicated, is ≤80 mg/dL.
- Ensure drug levels for medications that are or may be present and that suppress CNS function, if available, are in the therapeutic or subtherapeutic range and not considered to contribute to the neurologic state. If levels are unavailable:
- Allow at least 5 half-lives for all CNS-depressing medications or intoxicants to pass and longer if there is renal or hepatic dysfunction or if the patient is obese or was hypothermic (eTable 2, links.lww.com/WNL/D76).
- Account for age-dependent metabolism of potentially depressing medications in infants and young children and older patients (eTable 2, links.lww.com/WNL/D76).
- If the patient has received pentobarbital, the level must be <5 μg/mL or below the lower limit of detection for that laboratory before evaluation for BD/DNC.
- Exclude severe metabolic, acid-base, and endocrine derangements.
- Exclude the effect of pharmacologic paralysis, if administered or suspected, through use of a train-of-four stimulator or demonstration of deep tendon reflexes.
Performing the BD/DNC Neurologic Examination
Components of the BD/DNC Neurologic Examination
Assessment for Unresponsiveness
Assessment for Motor Response
Assessment of the Pupillary Light Reflex
Assessment of the OCR and the OVR
Assessment of the Corneal Reflex
Assessment of the Gag and Cough Reflexes
Assessment of the Sucking and Rooting Reflexes
Apnea Testing as Part of the BD/DNC Evaluation
Number of Apnea Tests Required
Procedure for Performing the Apnea Test
- In patients who are known NOT TO HAVE chronic CO2 retention, if (1) no respirations occur, (2) the arterial pH level is <7.30, and (3) the PaCO2 level is ≥60 and ≥20 mm Hg above the patient's preapnea test baseline level.
- In patients who are KNOWN TO HAVE chronic CO2 retention, and the baseline PaCO2 level is KNOWN, clinicians must conclude that the apnea test is consistent with BD/DNC criteria if (1) no respirations occur, (2) the arterial pH level is <7.30, and (3) the PaCO2 level is ≥60 and ≥20 mm Hg above the patient's known chronic elevated premorbid baseline level.
- In patients who are SUSPECTED TO HAVE chronic CO2 retention, but the baseline PaCO2 level is UNKNOWN, clinicians must conclude that the apnea test is consistent with BD/DNC criteria if (1) no respirations occur, (2) the arterial pH level is <7.30, and (3) the PaCO2 level is ≥60 and ≥20 mm Hg above the patient's baseline (pretest) level, AND ancillary testing must be performed.
- SBP <100 mm Hg or MAP <75 mm Hg in adults or SBP or MAP <fifth percentile for age in children despite titration of vasopressors, inotropes, and/or intravenous fluids, or
- Progressive decrease in oxygen saturation below 85%, or
- A cardiac arrhythmia with hemodynamic instability.
Procedure for Performing the Apnea Test in Patients on ECMO
- Preoxygenate by using 100% FiO2 on the ventilator and through the membrane lung.
- To achieve an adequate increase in PaCO2 level, either titrate exogenous CO2 into the ECMO circuit or adjust the sweep gas flow rate to 0.2–1 L/min.
- Sample ABG measurements from both the patient's distal arterial line and the ECMO circuit postoxygenator for patients on VA ECMO. PaCO2 and pH levels from both locations are required to meet BD/DNC criteria for the apnea test to be consistent with BD/DNC. This ensures that, independent of the mixing point, the PaCO2 and pH levels in the cerebral circulation meet BD/DNC criteria. For patients on venovenous ECMO, sample ABG measurements only from the patient's distal arterial line.
- Avoid hypotension during apnea testing on ECMO by increasing ECMO flows, intravenous fluid administration, or vasopressor/ionotropic support.
Ancillary Testing as Part of the BD/DNC Evaluation
Indications for Ancillary Testing
- Injuries such as fractures of the cervical spine, skull base, or orbits, severe facial injuries or abnormalities that preclude accurate assessment of any components of the neurologic examination (with the exception of the OCR if untestable due to concern for C-spine or skull base integrity), or injuries to the cervical spinal cord that limit the adequate assessment of extremity movement or spontaneous respirations, or
- The inability to perform or complete the apnea test safely because of the patient's risk of cardiopulmonary decompensation or the inability to interpret the PaCO2 levels in a patient with chronic hypercarbia for whom the chronic baseline PaCO2 level is unknown, or
- Neurologic examination findings that may be difficult to interpret, such as limb movements that may or may not be spinally mediated, or
- Metabolic derangements that are unable to be adequately corrected.
Tests of Electrophysiologic Function: EEG
Tests of Cerebral Perfusion: 4-Vessel Catheter Angiography
Tests of Cerebral Perfusion: Radionuclide Perfusion Scintigraphy
Tests of Cerebral Perfusion: Transcranial Doppler Ultrasonography
Tests of Cerebral Perfusion: CT and Magnetic Resonance Angiography
Obtaining Consent for BD/DNC Evaluation
Time of Death
Evaluation of BD/DNC in a Patient Who Is Pregnant
Primary Posterior Fossa Injury
- AAN: Academy Of Neurology
- AAP: American Academy Of Pediatrics
- ABG: Arterial Blood Gas
- AEP: Auditory Evoked Potential
- APP: Advanced Practice Provider
- BBB: Blood-brain Barrier
- BD/DNC: Brain Death/death By Neurologic Criteria
- COI: Conflict Of Interest
- CPAP: Continuous Positive Airway Pressure
- ECMO: Extracorporeal Membrane Oxygenation
- ETT: Endotracheal Tube
- HIBI: Hypoxic-ischemic Brain Injury
- MAP: Mean Arterial Pressure
- OCR: Oculocephalic Reflex
- OVR: Oculovestibular Reflex
- PEEP: Positive End-expiratory Pressure
- SBP: Systolic Blood Pressure
- SCCM: Society Of Critical Care Medicine
- SEP: Somatosensory Evoked Potential
- UDDA: Uniform Determination Of Death Act
- VA: Venoarterial
Pediatric and Adult Brain Death/Death by Neurologic Criteria
October 11, 2023
Last Updated Month/Year
November 6, 2023
Country of Publication
The purpose of this guideline is to update the 2010 American Academy of Neurology (AAN) brain death/death by neurologic criteria (BD/DNC) guideline for adults and the 2011 American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine guideline for infants and children and to clarify the BD/DNC determination process by integrating guidance for adults and children into a single guideline. Updates in this guideline include guidance related to conducting the BD/DNC evaluation in the context of extracorporeal membrane oxygenation, targeted temperature management, and primary infratentorial injury.
Target Patient Population
Adults and children with suspected brain death
Target Provider Population
Neurologists, surgeons, internists, pediatricians and other hospitalists caring for patients with suspected brain death
Male, Female, Adolescent, Adult, Child, Infant, Older adult
Health Care Settings
Emergency care, Home health, Hospice, Hospital, Long term care, Medical transportation, Operating and recovery room
Nurse, nurse practitioner, physician, physician assistant
Counseling, Diagnosis, Assessment and screening
D001926 - Brain Death, D001921 - Brain
death, brain death, BD/DNC, neurologic criteria, determination of death
Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline
Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM
David M. Greer, Matthew P. Kirschen, Ariane Lewis, Gary S. Gronseth, Alexander Rae-Grant, Stephen Ashwal, Maya A. Babu, David F. Bauer, Lori Billinghurst, Amanda Corey, Sonia Partap, Michael A. Rubin, Lori Shutter, Courtney Takahashi, Robert C. Tasker, Panayiotis Nicolaou Varelas, Eelco Wijdicks, Amy Bennett, Scott R. Wessels, John J. Halperin
Neurology Oct 2023, 10.1212/WNL.0000000000207740; DOI: 10.1212/WNL.0000000000207740