595: BRAIN DEATH ANCILLARY TEST: AN ETHICAL DILEMMA

Abstract

Introduction: Since the adoption of pediatric brain death certification in 1987, many legal and ethical dilemmas including practice variations have complicated brain death determination worldwide. We present an infant with a clinical exam consistent with neurologic death yet with intermittent discontinuous background activity on EEG. This case highlights further ethical challenges faced by intensivists in evaluating false positives and negatives in severe neurologic failure. Description: A 32-day-old female presented to the PICU after prolonged out-of-hospital cardiac arrest with fixed and dilated pupils and no spontaneous breathing, cough, or gag reflexes. Post-arrest care was initiated and an EEG was placed with initial very low amplitude to intermittent isoelectric findings, but after 72 hours began to show increased epileptiform activity that transitioned into discontinuous epileptiform activity. On day 20, she had a positive formal apnea test and met clinical criteria after three minutes for death by neurologic criteria. Given previous EEG findings, an EEG was repeated which again showed discontinuous background activity and intermittent low amplitude waves. Discussion: Ancillary testing for brain death is often utilized when a thorough clinical exam or apnea test is not possible. Though EEG was one of the first ancillary tests utilized, reports have suggested a 3.5% chance of false negative in death by neurologic criteria patients. Amongst ancillary tests, EEG has the highest rate of false negative results. The longest documented EEG activity in brain death patients was 14 days, whereas our patient is 3 weeks. Another diagnostic challenge, particularly in neonates, is occurrence of isoelectric findings with an exam not consistent with brain death. These patients may regain minimal cortical function, making institutional policies that use ancillary testing in addition to clinical exam criteria conflicting. In adult brain death guidelines, EEG testing is not recommended as a routine ancillary test due to its lack of sensitivity and specificity; however, it has been retained in many pediatric institutions. Further data is needed to characterize the utility of this practice and bioethical considerations with clinical diagnosis of brain death when isolated electrical activity is present.