Brain death diagnostic process in children after thiopental sedation: a comparative retrospective cohort study

Background

The determination of brain death (BD) is the primary pathway to organ donation in children. Thiopental is a sedative drug prescribed in critical situations potentially leading to BD and has been identified as a confounder during BD diagnosis. The implications of prior thiopental sedation on the diagnostic process of BD are poorly defined.

Objective

To compare the timeline and process involved in BD diagnosis between patients who received thiopental sedation versus those who did not.

Methods and Setting

Retrospective analysis was carried out on the healthcare records of all children who underwent the process of BD evaluation and diagnosis in our institution, between January 2012 and April 2020.

Results

74 patients were included; 29 had been treated with thiopental and 45 had received other sedatives or none. Median [IQR] time from reporting of suspected BD patients to apnea test (19.5 [11.5–30.2] vs 11.5 [5.4–21.1] hours, p = 0.015) and to BD confirmatory test (24.2 [7.2–32.6] vs 13.2 [6.2–23.5] hours, p = 0.019) was significantly longer in the thiopental group. Organ allocation was also delayed in the thiopental group. Thiopental plasma level was measured before BD examination in 24 patients, and the median concentration of the last assay was 4.6 [0.8–8.8] mg.L^-1. The BD diagnostic process included persistent signs of cerebral blood flow interruption on transcranial Doppler in 89.7 % of patients in the thiopental group vs 68.9 % in the other group (p = 0.049).

Conclusion

Prior administration of thiopental delays the process involved in the evaluation and diagnosis of BD in children in our intensive care unit. The diagnosis of BD after thiopental sedation requires a multimodal evaluation, which should include the monitoring of thiopental plasma levels and could be guided by transcranial Doppler.