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Variability in Brain Death Determination in Europe: Looking for a Solution

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Abstract

Background

Criteria for determining brain death (BD) vary between countries. We report the results of an investigation designed to compare procedures to determine BD in different European countries.

Methods

We developed a web-based questionnaire that was sent to representatives of 33 European countries. Responses were reviewed, and individual respondents were contacted if clarification was required.

Results

Responses were received from 28 (85 %) of the 33 countries to which the questionnaire was sent. Each country has either a law (93 %) or national guidance (89 %) for defining BD. Clinical examination is sufficient to determine BD in 50 % of countries; coma, apnea, absence of corneal, and cough reflexes are mandatory criteria in all. Confirmation of apnea is required in all countries but not defined in 4 (14 %). In the 24 (86 %) of countries with a formal definition of the apnea test, a target pCO2 level (23/24, 96 %) is the pre-specified end point in most. The (median, range) number of clinical examinations (2, 1–3) and minimum observation time between tests (3 h, 0–12 h) vary greatly between countries. Additional (confirmatory) tests are required in 50 % of countries. Hypothermia (4 %), anoxic injury (7 %), inability to complete clinical examination (61 %), toxic drug levels (57 %), and inconclusive apnea test (54 %) are among the most common indications for confirmatory tests. Cerebral blood flow (CBF) investigation is mandatory in 18 % of countries, but optional or indicated only in selected cases in 82 %. Conventional angiography is the preferred method of determining absent CBF (50 %), followed by transcranial Doppler sonography (43 %), computerized tomography (CT) angiography (39 %), CT perfusion, and magnetic resonance imaging (MRI) angiography (11 %). Electroencephalography is always (21 %) or optionally (14 %) recorded.

Conclusions

Although legislation or professional guidance is available to standardize nationally the BD diagnosis process in all European countries, there are still disparities between countries. The current variation in practice makes an international consensus for the definition of BD imperative.

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Acknowledgments

Danica Avsec ST, Institute for transplantation of organs and tissues of the Republic of Slovenia, Ljubljana, Slovenia; Paulo Azevedo Maia, Serviço Cuidados Intensivos 1, Hospital Santo António, Centro Hospitalar do Porto, Portugal; Ovidiu Bedreag, Anesthesiology and intensive care department, University of Medicine and Pharmacy Victor Babes Timisoara, Romania; Romuald Bohatyrewicz, Department of Anaesthesiology and Intensive Care, Pomeranian Medical University, Poland; Julien Charpentier, Medical Intensive Care Unit, Groupe Hospitalier Universitaire Cochin Broca Hôtel-Dieu, Paris, France; Martin Duenser, Department of Anesthesiology, Perioperative and General Intensive Care Medicine, Salzburg General Hospital and Paracelsus Private Medical University, Austria; Hans Friberg, Skåne University Hospital, Lund, Sweden; Hans Flaatten, Intensive Care Unit. Haukeland University Hospital. Bergen, Norway; Ivan Gornik, University of Zagreb Medical School, University Hospital Centre Zagreb, Croatia; Jozef Kesecioglu, Department of Intensive Care Medicine, University Medical Center Utrecht, Netherlands; Georgia Markou, Pediatric Intensive Care Medicine, University Hospital of Patras, Greece; Brian Marsh, Mater Misericordiae University Hospital, Dublin, Ireland; Kirsten Møller, Neurointensive Care Unit, Rigshospitalet, University of Copenhagen, Denmark; Pedro Navarrete-Navarro, Emergency & Critical Care Department, Hospital de Neuro-Traumatologia, Hospital Universitario Virgen de las Nieves, Granada, Spain; Mauro Oddo, Department of Intensive Care Medicine, CHUV-University Hospital; Faculty of Biology and Medicine, University of Lausanne, Switzerland; Vita Petronytė, Transplant Coordination Department, National Transplant Bureau, Lithuania; Ville Pettilä, Intensive Care Units, Helsinki University Central Hospital, Finland; Konstantin A. Popugaev, Neurocritical Care department, Burdenko Neurosurgical Research Institute, Moscow, Russia; Annika Reintam Blaser, Department of Anaesthesiology and Intensive Care, University of Tartu, Estonia; Fabio Silvio Taccone, Department of Intensive Care, Hopital Erasme, Brussels, Belgium; Lufti Telci, Istanbul Faculty of Medicine, Department of Anesthesiology and Intensive Care, Istanbul, Turkey; Csaba Varga, Kaposi Mor Teaching Hospital Emergency Department Kaposvár, Hungary.

Conflict of interest

All the authors declare that they have no conflict of interest.

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Authors and Affiliations

  1. NeuroIntensive Care Unit, Department of Anesthesia and Critical Care, Ospedale San Gerardo, Via Pergolesi 33, 20900, Monza, Italy

    Giuseppe Citerio, Ilaria Alice Crippa, Alfio Bronco & Alessia Vargiolu

  2. Department of Neurocritical Care, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK

    Martin Smith

  3. NIHR University College London Hospitals Biomedical Research Centre, London, UK

    Martin Smith

Authors
  1. Giuseppe Citerio
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  2. Ilaria Alice Crippa
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  3. Alfio Bronco
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  4. Alessia Vargiolu
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  5. Martin Smith
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Corresponding author

Correspondence to Giuseppe Citerio.

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Supplementary material Questionnaire submitted to participants. (DOC 19 kb)

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Citerio, G., Crippa, I.A., Bronco, A. et al. Variability in Brain Death Determination in Europe: Looking for a Solution. Neurocrit Care 21, 376–382 (2014). https://doi.org/10.1007/s12028-014-9983-x

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