COMMENTARY
The 2023 AAN/AAP/CNS/SCCM Pediatric and Adult
Brain Death/Death by Neurologic Criteria Consensus
Practice Guideline
A Comparison With the 2010 and 2011 Guidelines
Ariane Lewis, MD, Matthew P. Kirschen, MD, PhD, and David Greer, MD Correspondence
Dr. Lewis
Neurology: Clinical Practice 2023;13:e200189. doi:10.1212/CPJ.0000000000200189
Abstract
In collaboration with the American Academy of Pediatrics, Child Neurology Society, and
Society for Critical Care Medicine, the American Academy of Neurology formulated an
updated, evidence-informed consensus-based guideline for pediatric and adult brain death/
death by neurologic criteria (BD/DNC) determination. In comparison with the prior guide-
lines, the revisions and additions in this guideline, which are summarized in this review, are
intended to (1) ensure recommendations are conservative, yet practical, and emphasize cir-
cumstances in which BD/DNC determination should be delayed or deferred, so as to minimize
the risk of a false-positive BD/DNC determination; and (2) provide guidance about aspects of
BD/DNC determination that clinicians find challenging and/or controversial. We hope that
clinicians throughout the United States will use this information to revise their hospital BD/
DNC determination policies to conform to the standardized process for BD/DNC de-
termination described in the new guideline, to ensure that every BD/DNC evaluation is
consistent and accurate.
Introduction
In collaboration with the American Academy of Pediatrics (AAP), Child Neurology Society
(CNS), and Society for Critical Care Medicine (SCCM), the American Academy of Neurology
(AAN) formulated an updated, evidence-informed consensus-based guideline for pediatric and
adult brain death/death by neurologic criteria (BD/DNC) determination.1 The 2023 guideline,
which builds on the minimum standards for BD/DNC determination established in the World
Brain Death Project (WBDP) through international expert consensus, is based on multidisci-
plinary expertise from US adult and pediatric neurologists, intensivists, and neurosurgeons.1,2 It
replaces the 2010 AAN guideline for adult BD/DNC determination and the 2011 AAP, CNS, and
SCCM guideline for pediatric BD/DNC determination (hereafter referred to as “the prior
guidelines”), which were preceded by the 1995 AAN guideline for adult BD/DNC determination
and the 1987 guideline for pediatric BD/DNC determination published by the Task Force for the
Determination of Brain Death in Children, respectively.3-6
Although the prior pediatric and adult guidelines were very similar, there were a few notable
differences.7 The publication of a single guideline with recommendations for both pediatric and
adult BD/DNC determination represents successful achievement of one of the goals outlined at a
2016 multisociety summit organized by the AAN to improve public trust in BD/DNC de-
termination.8 In the 2023 guideline, recommendations for both pediatric and adult BD/DNC
determination are largely identical, but because of physiologic differences between children and
adults, and historical considerations, the 2023 guideline includes some age-specific guidance.
NYU Langone Medical Center (AL), NY; The Children’s Hospital of Philadelphia (MPK), PA; Boston University School of Medicine and Boston Medical Center (DG), MA.
Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at
Neurology.org/cp.
Copyright © 2023 American Academy of Neurology 1
Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
, In addition to synthesizing guidance for BD/DNC determination criteria” (or “BD/DNC”) in lieu of the term “brain death,” to
regardless of age, the 2023 guideline expands upon and updates both embrace the colloquial terminology and emphasize the
prior recommendations on (1) the prerequisites for BD/DNC equivalence to death by cardiopulmonary criteria.1-4 Second,
determination, (2) examinations/examiners, (3) apnea testing, the 2023 guideline uses the term “permanent” rather than
(4) ancillary testing, and (5) communication about BD/DNC “irreversible” to describe the severity of brain injury necessary
and BD/DNC declaration.1,3,4 It also addresses aspects of BD/ for BD/DNC determination; “permanent” is defined as “(1)
DNC determination that were not covered in the prior will not resume spontaneously and (2) medical interventions
guidelines, including BD/DNC evaluation after treatment with will not be used to attempt restoration of function.”1 An ex-
interventions to lower elevated intracranial pressure (ICP) or, tensive discussion of the rationale to use the term “permanent”
in the setting of primary infratentorial injury, preserved neu- in this context can be found elsewhere.12 Finally, the 2023
roendocrine function, targeted temperature management guideline interprets the UDDA, which requires “loss of all
(TTM), extracorporeal membrane oxygenation (ECMO), or functions of the entire brain, including the brainstem” as “loss
pregnancy; requirements for advanced practice providers of function of the brain as a whole, including the brainstem,
(APPs) to perform BD/DNC evaluations; absence of obliga- resulting in coma, brainstem areflexia and apnea in the setting
tion to obtain consent to initiate BD/DNC evaluation; and of an adequate stimulus.”1,9
information to include in hospital BD/DNC determination
policies about management of disagreements with families. Prerequisites for BD/DNC Determination
The intent of these changes and additions is to (1) ensure the Table 1 provides a detailed comparison of the guidance about
recommendations are conservative, yet practical, and empha- prerequisites for performance of a BD/DNC evaluation included
size the circumstances in which BD/DNC determination in the 2023 guideline and prior guidelines.1,3,4 Age-specific
should be delayed or deferred, so as to minimize the risk of a guidance is italicized. There are new recommendations (bold
false-positive BD/DNC determination, and (2) provide guid- text) about the etiology of brain injury, observation period after
ance about aspects of BD/DNC determination that clinicians brain injury and before initiating BD/DNC evaluation, severity
find challenging and/or controversial. of brain injury, neuroimaging results, temperature, blood pres-
sure, exclusion of intoxication, exclusion of pharmacologic pa-
The credibility of BD/DNC determination requires every ralysis, laboratory parameters, and other considerations.
evaluation to be consistent and accurate (i.e., there can be
no false-positive BD/DNC determinations), and the Uni- The 2023 guideline requires both a minimum systolic blood
form Determination of Death Act (UDDA) requires de- pressure (SBP) and a mean arterial pressure (MAP), whereas
terminations of death to be made in accordance with the prior guidelines required either a minimum SBP or
accepted medical standards.9 To facilitate this, hospital MAP.1,3,4 Because blood pressure is age-dependent, the 2023
BD/DNC determination policies must conform to stan- guideline requires SBP ≥100 mm Hg and MAP ≥75 mm Hg in
dardized guidelines established by relevant national medical so- adults and both SBP and MAP ≥5th percentile for age in
cieties. Reviews of US hospital BD/DNC determination policies children. For patients who have a baseline blood pressure that
after publication of the prior guidelines demonstrated variability varies significantly from their age-based normal blood pressure,
in the exclusion of confounding conditions, examinations/ the 2023 guideline recommends targeting SBP and MAP that
examiners, apnea testing, and ancillary testing.10,11 To promote approximate the known chronic baseline blood pressure.
consistency between US hospital BD/DNC determination
policies and the 2023 guideline, we herein review differences To exclude intoxication, the 2023 guideline provides a
between the 2023 guideline and prior guidelines and highlight pharmacokinetic table for common drugs that can depress
new topics. We hope that clinicians throughout the United the CNS and recommends ensuring serum drug levels are
States will use this information to revise their hospital BD/DNC within the therapeutic or subtherapeutic range, when able,
determination policies to conform to the standardized process with specific mention that the pentobarbital level (if ad-
for BD/DNC determination described in the 2023 guideline so ministered) must be < 5 μg/mL or below the lower limit of
that every BD/DNC evaluation performed in every hospital by detection for the laboratory.
every clinician is consistent and accurate.
In addition, although the 2023 guideline acknowledges that
there is no scientific rationale to identify acceptable electro-
Differences Between the 2023 lyte or metabolic thresholds for BD/DNC determination, it
Guideline and the Prior Guidelines includes a table with ranges of values that warrant correction
and/or performance of ancillary testing.
Terminology
There are 3 notable differences between terminology in the Examinations/Examiners
2023 guideline and the prior guidelines.1,3,4 Although these Table 2 compares the guidance in the 2023 guideline and
differences do not affect the process or accuracy of BD/DNC prior guidelines about the examinations/examiners for
determination, they warrant mention. First, like the WBDP, the BD/DNC determination.1,3,4 Age-specific guidance is
2023 guideline uses the term “brain death/death by neurologic italicized. There are new recommendations (bold text)
2 Neurology: Clinical Practice | Volume 13, Number 6 | December 2023 Neurology.org/CP
Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
The 2023 AAN/AAP/CNS/SCCM Pediatric and Adult
Brain Death/Death by Neurologic Criteria Consensus
Practice Guideline
A Comparison With the 2010 and 2011 Guidelines
Ariane Lewis, MD, Matthew P. Kirschen, MD, PhD, and David Greer, MD Correspondence
Dr. Lewis
Neurology: Clinical Practice 2023;13:e200189. doi:10.1212/CPJ.0000000000200189
Abstract
In collaboration with the American Academy of Pediatrics, Child Neurology Society, and
Society for Critical Care Medicine, the American Academy of Neurology formulated an
updated, evidence-informed consensus-based guideline for pediatric and adult brain death/
death by neurologic criteria (BD/DNC) determination. In comparison with the prior guide-
lines, the revisions and additions in this guideline, which are summarized in this review, are
intended to (1) ensure recommendations are conservative, yet practical, and emphasize cir-
cumstances in which BD/DNC determination should be delayed or deferred, so as to minimize
the risk of a false-positive BD/DNC determination; and (2) provide guidance about aspects of
BD/DNC determination that clinicians find challenging and/or controversial. We hope that
clinicians throughout the United States will use this information to revise their hospital BD/
DNC determination policies to conform to the standardized process for BD/DNC de-
termination described in the new guideline, to ensure that every BD/DNC evaluation is
consistent and accurate.
Introduction
In collaboration with the American Academy of Pediatrics (AAP), Child Neurology Society
(CNS), and Society for Critical Care Medicine (SCCM), the American Academy of Neurology
(AAN) formulated an updated, evidence-informed consensus-based guideline for pediatric and
adult brain death/death by neurologic criteria (BD/DNC) determination.1 The 2023 guideline,
which builds on the minimum standards for BD/DNC determination established in the World
Brain Death Project (WBDP) through international expert consensus, is based on multidisci-
plinary expertise from US adult and pediatric neurologists, intensivists, and neurosurgeons.1,2 It
replaces the 2010 AAN guideline for adult BD/DNC determination and the 2011 AAP, CNS, and
SCCM guideline for pediatric BD/DNC determination (hereafter referred to as “the prior
guidelines”), which were preceded by the 1995 AAN guideline for adult BD/DNC determination
and the 1987 guideline for pediatric BD/DNC determination published by the Task Force for the
Determination of Brain Death in Children, respectively.3-6
Although the prior pediatric and adult guidelines were very similar, there were a few notable
differences.7 The publication of a single guideline with recommendations for both pediatric and
adult BD/DNC determination represents successful achievement of one of the goals outlined at a
2016 multisociety summit organized by the AAN to improve public trust in BD/DNC de-
termination.8 In the 2023 guideline, recommendations for both pediatric and adult BD/DNC
determination are largely identical, but because of physiologic differences between children and
adults, and historical considerations, the 2023 guideline includes some age-specific guidance.
NYU Langone Medical Center (AL), NY; The Children’s Hospital of Philadelphia (MPK), PA; Boston University School of Medicine and Boston Medical Center (DG), MA.
Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at
Neurology.org/cp.
Copyright © 2023 American Academy of Neurology 1
Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
, In addition to synthesizing guidance for BD/DNC determination criteria” (or “BD/DNC”) in lieu of the term “brain death,” to
regardless of age, the 2023 guideline expands upon and updates both embrace the colloquial terminology and emphasize the
prior recommendations on (1) the prerequisites for BD/DNC equivalence to death by cardiopulmonary criteria.1-4 Second,
determination, (2) examinations/examiners, (3) apnea testing, the 2023 guideline uses the term “permanent” rather than
(4) ancillary testing, and (5) communication about BD/DNC “irreversible” to describe the severity of brain injury necessary
and BD/DNC declaration.1,3,4 It also addresses aspects of BD/ for BD/DNC determination; “permanent” is defined as “(1)
DNC determination that were not covered in the prior will not resume spontaneously and (2) medical interventions
guidelines, including BD/DNC evaluation after treatment with will not be used to attempt restoration of function.”1 An ex-
interventions to lower elevated intracranial pressure (ICP) or, tensive discussion of the rationale to use the term “permanent”
in the setting of primary infratentorial injury, preserved neu- in this context can be found elsewhere.12 Finally, the 2023
roendocrine function, targeted temperature management guideline interprets the UDDA, which requires “loss of all
(TTM), extracorporeal membrane oxygenation (ECMO), or functions of the entire brain, including the brainstem” as “loss
pregnancy; requirements for advanced practice providers of function of the brain as a whole, including the brainstem,
(APPs) to perform BD/DNC evaluations; absence of obliga- resulting in coma, brainstem areflexia and apnea in the setting
tion to obtain consent to initiate BD/DNC evaluation; and of an adequate stimulus.”1,9
information to include in hospital BD/DNC determination
policies about management of disagreements with families. Prerequisites for BD/DNC Determination
The intent of these changes and additions is to (1) ensure the Table 1 provides a detailed comparison of the guidance about
recommendations are conservative, yet practical, and empha- prerequisites for performance of a BD/DNC evaluation included
size the circumstances in which BD/DNC determination in the 2023 guideline and prior guidelines.1,3,4 Age-specific
should be delayed or deferred, so as to minimize the risk of a guidance is italicized. There are new recommendations (bold
false-positive BD/DNC determination, and (2) provide guid- text) about the etiology of brain injury, observation period after
ance about aspects of BD/DNC determination that clinicians brain injury and before initiating BD/DNC evaluation, severity
find challenging and/or controversial. of brain injury, neuroimaging results, temperature, blood pres-
sure, exclusion of intoxication, exclusion of pharmacologic pa-
The credibility of BD/DNC determination requires every ralysis, laboratory parameters, and other considerations.
evaluation to be consistent and accurate (i.e., there can be
no false-positive BD/DNC determinations), and the Uni- The 2023 guideline requires both a minimum systolic blood
form Determination of Death Act (UDDA) requires de- pressure (SBP) and a mean arterial pressure (MAP), whereas
terminations of death to be made in accordance with the prior guidelines required either a minimum SBP or
accepted medical standards.9 To facilitate this, hospital MAP.1,3,4 Because blood pressure is age-dependent, the 2023
BD/DNC determination policies must conform to stan- guideline requires SBP ≥100 mm Hg and MAP ≥75 mm Hg in
dardized guidelines established by relevant national medical so- adults and both SBP and MAP ≥5th percentile for age in
cieties. Reviews of US hospital BD/DNC determination policies children. For patients who have a baseline blood pressure that
after publication of the prior guidelines demonstrated variability varies significantly from their age-based normal blood pressure,
in the exclusion of confounding conditions, examinations/ the 2023 guideline recommends targeting SBP and MAP that
examiners, apnea testing, and ancillary testing.10,11 To promote approximate the known chronic baseline blood pressure.
consistency between US hospital BD/DNC determination
policies and the 2023 guideline, we herein review differences To exclude intoxication, the 2023 guideline provides a
between the 2023 guideline and prior guidelines and highlight pharmacokinetic table for common drugs that can depress
new topics. We hope that clinicians throughout the United the CNS and recommends ensuring serum drug levels are
States will use this information to revise their hospital BD/DNC within the therapeutic or subtherapeutic range, when able,
determination policies to conform to the standardized process with specific mention that the pentobarbital level (if ad-
for BD/DNC determination described in the 2023 guideline so ministered) must be < 5 μg/mL or below the lower limit of
that every BD/DNC evaluation performed in every hospital by detection for the laboratory.
every clinician is consistent and accurate.
In addition, although the 2023 guideline acknowledges that
there is no scientific rationale to identify acceptable electro-
Differences Between the 2023 lyte or metabolic thresholds for BD/DNC determination, it
Guideline and the Prior Guidelines includes a table with ranges of values that warrant correction
and/or performance of ancillary testing.
Terminology
There are 3 notable differences between terminology in the Examinations/Examiners
2023 guideline and the prior guidelines.1,3,4 Although these Table 2 compares the guidance in the 2023 guideline and
differences do not affect the process or accuracy of BD/DNC prior guidelines about the examinations/examiners for
determination, they warrant mention. First, like the WBDP, the BD/DNC determination.1,3,4 Age-specific guidance is
2023 guideline uses the term “brain death/death by neurologic italicized. There are new recommendations (bold text)
2 Neurology: Clinical Practice | Volume 13, Number 6 | December 2023 Neurology.org/CP
Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
