美国南加州大学Gene Sung团队研究了用神经学标准确定脑死亡/死亡的临床标准。该成果于2020年8月3日发表在《美国医学会杂志》上。

在国内外，根据神经学标准（BD/DNC），脑死亡/死亡的概念、标准、实践和记录等方面存在不一致。

为了制定共识声明，研究组召集相关的国际专业协会以制定有关确定BD/DNC的建议。研究组在Cochrane、Embase和MEDLINE数据库中检索1992年1月1日至2020年4月的相关文章并进行审查。根据相关学科（包括重症监护、神经病学和神经外科）的贡献者和医学会的共识提出建议。研究组基于对文献的回顾和国际大型多学科小组的共识，制定了在各种情况下确定BD / DNC所需的最低临床标准。

在评估患者是否为BD/DNC之前，患者应有一个确定的神经系统诊断，该诊断可能导致所有大脑功能的完全和不可逆的丧失，并排除可能混淆临床检查的情况和类似BD/DNC的疾病。BD/DNC的确定可通过表现昏迷、脑干活动迟缓和呼吸暂停等临床检查来进行。即，（1）对最大的外部刺激（包括伤害性视觉、听觉和触觉刺激）无觉醒或意识；（2）瞳孔固定在中等大小或扩张的位置，对光线无反应；（3）角膜、头眼、眼前庭反射消失；（4） 对有害刺激无面部运动；（5）双侧咽后刺激无呕吐反射；（6）深部气管吸痰无咳嗽反射；（7）肢体伤害性刺激时脑介导的运动反应消失；（8）当呼吸暂停试验指标达到pH<7.30和PaCO₂≥60mmhg时，未观察到自发性呼吸。

如果无法完成临床检查，可以考虑通过血流检查或电生理检查进行辅助检查。儿童、接受体外膜氧合的人、接受治疗性体温过低的人，以及社会、文化观点等因素，法律要求，和资源可用性都需要特别考虑。

总之，该研究为成人和儿童通过神经系统标准确定脑死亡/死亡的最低临床标准提供了建议，并针对各种临床情况提供了明确的指导。这些建议得到了国际社会的广泛认可，可以指导专业协会和国家修订或制定通过神经系统标准确定脑死亡/死亡的协议和程序，使国内外标准更一致。

附：英文原文

Title: Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project

Author: David M. Greer, Sam D. Shemie, Ariane Lewis, Sylvia Torrance, Panayiotis Varelas, Fernando D. Goldenberg, James L. Bernat, Michael Souter, Mehmet Akif Topcuoglu, Anne W. Alexandrov, Marie Baldisseri, Thomas Bleck, Giuseppe Citerio, Rosanne Dawson, Arnold Hoppe, Stephen Jacobe, Alex Manara, Thomas A. Nakagawa, Thaddeus Mason Pope, William Silvester, David Thomson, Hussain Al Rahma, Rafael Badenes, Andrew J. Baker, Vladimir Cerny, Cherylee Chang, Tiffany R. Chang, Elena Gnedovskaya, Moon-Ku Han, Stephen Honeybul, Edgar Jimenez, Yasuhiro Kuroda, Gang Liu, Uzzwal Kumar Mallick, Victoria Marquevich, Jorge Mejia-Mantilla, Michael Piradov, Sarah Quayyum, Gentle Sunder Shrestha, Ying-ying Su, Shelly D. Timmons, Jeanne Teitelbaum, Walter Videtta, Kapil Zirpe, Gene Sung

Issue&Volume: 2020-08-03

Abstract:

Importance  There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries.

Objective  To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel.

Process  Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery.

Evidence Synthesis  Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed.

Recommendations  Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability.

Conclusions and Relevance  This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.

DOI: 10.1001/jama.2020.11586

Source: https://jamanetwork.com/journals/jama/fullarticle/2769149