Mahmut ASLAN, Serkan KIRIK, Bilge ÖZGÖR, Neslihan ASLAN, Serdal GÜNGÖR

Evaluation of Brain Death in Children: A Single Center Experience

Giriş ve Amaç: Beyin ölümü apne, koma ve beyin sapı reflekslerinin bulunmamasına ek olarak elektroserebral sessiz elektroensefalografi (EEG) bulunması durumudur. Çocuklarda beyin ölümü en sık travma ve anoksik ensefalopati sonucu ortaya çıkar. Beyin ölümü insidansının %0,65 ila %1,2 arasında değiştiğini bildirmiştir. Beyin ölümü tanısı iyi bir anamnez, fizik muayene ve yardımcı testler ile konulur. Pediatrik hastalar EEG açısından değerlendirilirken mutlaka medikasyon, metabolik ensefalopati, hipotermi, elektrolit dengesizliği, asit-baz dengesizliği açısında değerlendirilmelidir. Hastalar ve Metod: Çalışmamıza 2010-2017 yılları arasında İnönü Üniversitesi Turgut Özal Tıp Merkezi çocuk yoğun bakım ünitesinde beyin ölümü gerçekleşen hastalar alınmıştır. Hastaların dosyaları retrospektif olarak tarandı. Çalışmamıza alınan hastaların tamamına EEG çekildi. Hastalarımızın tamamına apne testi yapıldı. Beyin kan akımı (CSF) akımı ölçümünde bilgisayarlı tomografi anjiyografi (BTA), manyetik rezonans anjiyografi (MRA), transkraniyal doppler ultranografi (TCD) yapıldı. Sonuçlar: Çalışmamıza alınan 20 hastanın 9’u (%45) kız, 11’i (%55) erkekti. Yaş ortalaması ise 8,47±5,73 yaş idi. Hastalarımızın 7’si fulminan hepatit, 3’ü travma, 3’ü sepsis, 2’si suda boğulma, 2’si SVO tanısı, birer hasta ise lenfoma, suicide, elektrik çarpması ile takip edilmişti. Yirmi hastamızın sadece 2’si (%10) için aile organ bağışında bulunmuştu. Yirmi hastamızın 4’ü Suriyeli idi ve 4 hastanın tamımı da karaciğer yetmezliği ile takip edilmekteydi. Tüm hastaların apne testi pozitifti, hastalarımızın tamamında EEG bulguları beyin ölümünü destekleyici nitelikteydi. Hastalarımızın 11’ine (%55) CSF akımının yokluğunu gösterebilmek adına görüntüleme yöntemleri yapıldı. Beyin ölümü gerçekleşen hastalarımızın 9’unda (%45) DI gelişti. Sonuç: Sonuç olarak beyin ölümü tanısı multidisipliner yaklaşım gerektirir. Fizik muayenenin yanında laboratuvar bulgularının EEG’nin birlikte değerlendirilmesi özellikle klinğimiz gibi 50’den fazla pediatrik transplantın yapıldığı merkezler açısından önemlidir. Hastalarda hipernatremi ve DI gelişimi beyin fonksiyonlarında kaybın bir göstergesidir.

Anahtar Kelimeler:

Beyin ölümü, Çocukluk çağı, EEG

Evaluation of Brain Death in Children: A Single Center Experience

Introduction: Brain death is defined as a status of apnea, coma and the absence of brainstem reflexes, in addition to the presence of electrocerebral silence (ECS) on an electroencephalography (EEG). Trauma and anoxic encephalopathy are the most common causes of brain death in children, with incidences of brain death reported to vary between 0.65–1.2 percent. A diagnosis of brain death can be made based on a detailed anamnesis, physical examination findings and supportive test results. When pediatric patients are being evaluated by EEG, they should also be assessed in terms of medications, metabolic encephalopathy, hypothermia, electrolyte imbalance and acid-base imbalance. Patients and Methods: The present study included patients who suffered brain death during hospitalization in the pediatric intensive care unit of Inonu University Turgut Ozal Medical Center between 2010 and 2017. The medical files of the patients were reviewed retrospectively. All patients included in the study underwent an EEG and an apnea test was performed on all patients. The cerebral blood flow (CBF) measurement was obtained through a Computerized Tomography Angiography (CTA), and all patients underwent a Magnetic Resonance Angiography (MRA) and a Transcranial Doppler Ultrasonography (TCD). Results: Of the 20 patients included in the study, nine (45%) were female and 11 (55%) were male, with a mean age of 8.47±5.73 years. Of the total, seven patients presented with fulminant hepatitis, three with trauma, three with sepsis, two with drowning, two with cerebrovaskuler disease (CVD), and one patient each with lymphoma, suicide and electric shock. The families of only two (10%) patients donated the organs of the deceased. Of the 20 patients, four were Syrian, and of which were being monitored with the diagnosis of liver failure. An apnea test was positive in all patients, and in all patients, the EEG findings supported brain death. Imaging methods were carried out to demonstrate the absence of CBF flow in 11 (55%) patients, and diabetes insipidus (DI) developed in nine (45%) of the patients with brain death. Conclusion: In conclusion, a multidisciplinary approach is required for the diagnosis of brain death. An evaluation of laboratory findings and EEG results together with the findings of a physical examination is important, particularly in centers like our clinics where more than 50 pediatric transplantations are carried out each year. The development of hypernatremia in patients with DI is now an important parameter in the loss of brain function.

Keywords:

Brain death, Childhood, EEG,

PDF

___

American Academy of Pediatrics, Task Force on Brain Death in Children. Report of Special Task Force: guidelines for determination of brain death in children. Pediatrics. 1987; 80: 298 –300.
Nakagawa TA, Ashwal S, Mathur M, Mysore M. Society of Critical Care Medicine, Section on Critical Care and Section on Neurology of American Academy of Pediatrics; Child Neurology Society. Clinical report—Guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations. Pediatrics. 2011; 128: 720-40.
Nakagawa TA, Ashwal S, Mathur M, Mysore MR, Bruce D, Conway EE Jr, et al. Society of Critical Care Medicine; Section on Critical Care and Section on Neurology of the American Academy of Pediatrics; Child Neurology Society. Guidelines for the determination of brain death in infants and children: an update of the 1987 Task Force recommendations. Crit Care Med. 2011; 39: 2139-55.
American Electroencephalographic Society. Guideline three: minimum technical standards for EEG recording in suspected cerebraldeath. J Clin Neurophysiol. 1994; 11: 10–3.
Coker SB, Dillehay GL. Radionuclide cerebral imaging for confirmation of brain death in children: the significance of dural sinus activity. Pediatr Neurol. 1986; 2: 43–46.
Ashwal S, Smith AJ, Torres F, Loken M, Chou SN. Radionuclide bolus angiography: a technique for verification of brain death in infants and children. J Pediatr. 1977; 91: 722-7.
Garrett MP, Williamson RW, Bohl MA, Bird CR, Theodore N. Computed tomography angiography as a confirmatory test for the diagnosis of brain death. J Neurosurg. 2017; 17: 1-6.
Drake M, Bernard A, Hessel E. Brain Death. Surg Clin North Am. 2017; 97: 1255-73.
Kainuma M, Miyake T, Kanno T. Extremely prolonged vecuronium clearance in a brain death case. Anesthesiology 2001; 95(4): 1023-4.
Ostermann ME, Young B, Sibbald WJ, Nicolle MW. Coma mimicking brain death following baclofen overdose. Intensive Care Med 2000; 26(8): 1144-6.
Gençpınar P, Dursun O, Tekgüç H, Ünal A, Haspolat Ş, Duman Ö. Pediatric Brain Death: Experience of a Single Center Turkiye Klinikleri J Med Sci. 2015; 35(2): 60-6.
Au AK, Carcillo JA, Clark RS, Bell MJ. Brain injuries and neurological system failure are the most common proximate causes of death in children admitted to a pediatric intensive care unit. Pediatr Crit Care Med 2011; 12: 566-571.
Joffe AR, Shemie SD, Farrell C, Hutchison J, McCarthy-Tamblyn L. Brain death in Canadian PICUs: demographics, timing, and irreversibility. Pediatr Crit Care Med 2013; 14: 1-9.
Gündüz C, Şahin Ş, Uysal-Yazıcı M, et al. Brain death and organ donation of children. The Turkish Journal of Pediatrics 2014; 56: 597-603.
Ashwal S, Serna-Fonseca T. Brain death in infants and children. Crit Care Nurse 2006; 26: 117-124, 126-128.
Tsai WH, Lee WT, Hung KL. Determination of brain death in children—a medical center experience. Acta Paediatr Taiwan 2005; 46: 132-137.
Alharfi IM, Stewart TC, Foster J, Morrison GC, Fraser DD. Central diabetes insipidus in pediatric severe traumatic brain injury. Pediatr Crit Care Med 2013; 14(2): 203-9.
Shemie SD, Pollack MM, Morioka M, Bonner S. Diagnosis of brain death in children. Lancet Neurol 2007; 6: 87-92.