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Neonatal Intensive Care Unit A. Chatziioannidis, 3B Ag. Triados Str. It is considered the result of an acute and irreversible central nervous system test ocular la stand. Asphyxia, severe intracranial hemorrhage and infection are the most common causes of test ocular la stand death in children. BD diagnosis is usually based on clinical criteria.

Because of major differences of brain function in this age group, brain death should be established with extreme caution. Comparative to adults' test ocular la stand observational periods at least 24 hours apart and specific neurodiagnostic tests, by at least two expert physicians, are needed to ascertain an irreversible loss of brain function. Test ocular la stand objective of this article is to present current guidelines for BD determination in newborns and to refer their application in Greece.

Keywords: Brain death, electroencephalography, cerebral blood flow, newborn Introduction Brain death BD is the permanent and irreversible loss of brainstem and cortical function 1. Terms like brain stem, neocortical and whole brain death are not identical 2.

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Loss of brain function, arises medical, ethical and philosophical issues 3. Loss of brain function is also loss of human life, even though heart and spinal cord may still operate 4 - 6.

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Development of cardiorespiratory support in neonatal intensive care units NICU'sarouse the need to define BD criteria in newborns 7. BD diagnosis is vital for parents and medical staff to help them decide if a newborn should be supported further or not.

Is brain death diagnosis in newborns feasible?

Determination of brain death in newborns is based mainly on clinically accepted neurologic criteria 11 Age related observational periods and the need for neurodiagnostic tests are still needed to be evaluated for BD diagnosis in children under 1 year of age 12 Considering variation for BD diagnosis guidelines in children from country to country, these have not been clearly established in Greece 1214 This review discusses current accepted definition, diagnosis and appropriate testing for brain death in newborns.

Epidemiology In neonatal units, the percentage of BD among deaths has been found 1 — 6. BD newborns are comatose, apneic with their brainstem reflexes absent It is of great importance to confirm BD in newborns with serial clinical neurologic examinations and ancillary tests.

Harvard Committee in and Medical Consultants Report in established guidelines for the determination of BD in adults based on neurological criteria 39 Inthe American Task Force for the Determination of BD in children, established guidelines in the age group under 7 years old, while preterm and term infants under 7 days old were excluded because of insufficient data In a report of a Working Party of the Test ocular la stand Paediatric Association recommended that the criteria test ocular la stand for adults can only be applied in children over the age of two months Recent studies suggest that BD criteria in infants under 2 months of age can also be used for preterm and term infants within the first week of life 7 These guidelines are based in definition of coma cause, irreversible cessation of entire brain's function specifically brain stemexclusion of reversible causes, clinical neurological examination criteria, neurodiagnostic tests and suggestion of specific observational periods according to age Table 1.

Table 1 Brain death guidelines in ce este viziunea plus unu modified form from Ad Hoc Task Force guidelines for the determination. Open este test ocular la stand să se vindece vederea slabă? a separate window Diagnosis Brain dead patients supported on mechanical ventilation, are comatose, apneic and lack brain stem reflexes 7.

BD diagnosis requires clarification of: Etiology, clinical examination, apnea and ancillary testing.


Common causes of BD in neonates are perinatal asphyxia, birth trauma, central nervous system CNS infection, malformations, severe intracranial hemorrhage intraventricular hemorrhage grade IV and metabolic diseases Neurologic examination remains the cornerstone for determination of BD Grimacing or motor response withdrawal movements to stimuli or in response to brainstem reflexes excludes BD diagnosis.

Inability to apply clinical criteria e. Euvolemia, normal blood pressure, normal pCO2 and preoxygenation for minutes are prerequisites for an appropriate apnea test 8. Neurodiagnostic ancillary tests offer information for whole brain death and regarding the key role of brain stem function in BD diagnosis should be used under certain conditions.

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Ancillary tests are required when neurologic examination cannot be evaluated reliably i. Neurodiagnostic electrophysiologic tests [electroencephalography EEGbrainstem auditory evoked potentials BAEPssomatosensory evoked potentials SEPs ] can assess brain electrical activity.

EEG's role in determining BD diagnosis is controversial since it cannot record brainstem function cessation.

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Patients with electro cerebral silence ECS on their EEG may have normal brainstem function and vice-versa in BD patients with loss of brain function, cortical activity even transitory may be traced. Absence of electrical activity ECS for at least 30 minutes on the initial EEG supports the diagnosis of brain death 2 Published case reports have shown preservation or recovery of brain function after a period of time in brain dead infants with with some degree of EEG activity minimum or transient Dalnoopia miopie. Most infants died within a short period of time while those who survived recovered with severe neurologic complications 1024 - In this case, EEG activity is considered an artifact and for BD diagnosis additional testing is needed.

Likewise, test ocular la stand newborns once the diagnosis of BD is established recovery is unlikely to happen, since there are no reports of any newborn that developed respiratory effort after brain death determination 8.

Brain blood flow tests [radionuclide angiography, digital subtraction angiography] are invaluable to confirm BD diagnosis 7 Evidence of low cerebral blood flow, with a repeat no flow on CBF study after, establishes diagnosis of BD.

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Two clinical examinations separated by an observational period of 24 hours for term newborns 37 weeks GA to 30 days of age by two expert medical practitioners one should be a pediatrician consultant registered for more than 5 years and one who's not primarily involved in the newborn's care are required to establish BD diagnosis.

The importance of defining a certain observation time and the presence of experienced physicians is based on the need to re-evaluate the nonfunctioning brain and reduce the possibility of an error 2.

Consequently, the observational period for BD diagnosis at terms, from 24 hours could be reduced when an isoelectric EEG or a no flow on a CBF study is established.

If an EEG confirms some degree test ocular la stand activity or a CBF study shows evidence of flow it is recommended a repeat clinical umbrele obiectelor la vedere rather than an ancillary test, confirming BD diagnosis after a 24 hours observational period 8. NICU's policy for BD diagnosis in newborns is not based to a specific checklist, because of lack of certain guidelines.

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  2. Is brain death diagnosis in newborns feasible?
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New guidelines for BD in newborns should be established and implemented on a national basis. BD should be based mainly on neurological clinical examination and ancillary testing. Combination of neurologic examination, ECS and no flow on CBF study in a preterm or term newborn for 24 hours observational period is confirmatory of BD.

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BD diagnosis helps parents and medical staff to realize newborns' condition. Medical staff should always support and help parents in every decision they'll take dis- or continuation of life support based on a mixture of sensitivity and factuality.

Conflict of interest The authors declare no conflicts of interest. References 1. Brain death documentation: analysis and issues. Declaring pediatric brain death: current practice in a Canadian pediatric critical care unit.

Can Med Assoc J. Machado C. Diagnosis of brain death. Neurol Int. Korein J, Machado C. Brain death - updating a valid concept for Adv Exp Med Biol. The first organ transplant from a brain-dead donor. Wijdicks EF.

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The neurologist and Harvard criteria for brain death. Determination of death by neurological criteria. J Intensive Care Med. Imaging of brain death in neonates and young infants. J Paediatr Child Health.

Okamoto K, Sugimoto T. Return of spontaneous respiration in an infant who fulfilled current criteria to determine brain death. Banasiak KJ, Lister G. Brain test ocular la stand in children. Curr Opin in Pediatrics. Goh AY, Mok Q.

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Clinical course and determination of brain death in a children's hospital. Acta Paediatr.

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Ashwal S. Brain Death in children. In: Current management in child neurology, 3rd ed. Maria BL, editor.

Suspiciunea de VPPB este confirmată prin examenul clinic: în poziţia Dix-Hallpike de partea res­pectivă figura 3după o latenţă de de secunde, apare nistagmus intens, orizonto-rotator geotropic, însoţit de vertij. Acest nistagmus, ca şi senzaţia de vertij se epuizează dacă se menţine poziţia capului aproximativ un minut fatigabilitate. La revenirea în şezut, pacientul poate prezenta nistagmus cu sens opus sau nistagmus inferior, mai puţin sever, epuizabil. Repetarea manevrei declanşatoare demonstrează adaptabilitatea nistagmusului poziţional benign, caracteristică patognomonică a acestei afecţiuni. Figura 3.

London Hamilton. Decker Inc. Brain death wordwide: accepted fact but no global consensus in diagnostic criteria.

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Jan MM. Brain death criteria. The neurological determination of death. Neurosciences Riyadh ;— Your child is brain dead. Postgrad Med.

Inima poate vindeca acel ochi al tău. Heart can heal that eye of yours. Un astfel de rege este un adevãrat ochi al omenirii, podoaba luminoasã pe fruntea creaţiei, izvorul binecuvântãrilor în întreaga lume. Such a king is the very eye of mankind, the luminous ornament on the brow of creation, the fountain-head of blessings unto the whole world. Și el vine până în prezent pe hârtia de un dolar din Statele Unite, care are pe ea un ochi al providenței.

Report of special Task Force. Guidelines for the determination of brain death in children.

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Ashwal S, Serna-Fonseca T. Brain death in infants and children.

Vertijul paroxistic poziţional benign (VPPB)

Crit Care Nurse. Determination of death. Acta Anaesthesiol Scand. In: Brain Death. Wijdicks EFM, editor.