Development of a bedside tool to predict time to death after withdrawal of life-sustaining therapies in infants and children.

OBJECTIVES: To generate a preliminary bedside predictor of rapid time-to-death after withdrawal of support in children to help identify potential candidates for organ donation after circulatory death. DESIGN: Retrospective chart review. SETTING: Pediatric intensive care unit of an academic children's hospital. PATIENTS: All deaths in the pediatric intensive care unit from May 1996 to April 2007. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 1389 deaths, 634 patients underwent withdrawal of support and 518 with complete data regarding demographics, life-supportive therapies, and end-of-life circumstances were analyzed. Three hundred seventy-three (72%) patients died within 30 mins of withdrawal and 452 (87%) died within 60 mins. Using multiple logistic regression, significant predictors of death within 30 or 60 mins (typical cut-off times for organ donation) were identified and a predictor score was generated. Significant predictors included: age 1 month or younger; norepinephrine, epinephrine, or phenylephrine >0.2 µg/kg/min; extracorporeal membrane oxygenation; and positive end-expiratory pressure >10 cmH2O; and spontaneous ventilation. Possible scores for the 30-min predictor ranged from -17 to 67; a score ≤-9 predicted a 37% probability of death ≤ 30 mins, whereas a score ≥ 38 predicted an 85% probability of death within 30 mins. For the 60-min predictor, scores ranged from -21 to 38; score ≤-10 predicted a 59% probability of death within 60 mins and a score ≥ 16 predicted a 98% probability of death within 60 mins. CONCLUSIONS: This tool is a reasonable preliminary predictor for death within 30 or 60 mins after withdrawal of support in terminally ill or injured children and might assist in identifying potential pediatric candidates for donation after circulatory death, although prospective validation is required.

Potential for liver and kidney donation after circulatory death in infants and children.

OBJECTIVE: To determine the potential effect of organ donation after circulatory death (DCD) on the number of kidney and liver donors in a PICU. PATIENTS AND METHODS: All deaths in the PICU of an academic, tertiary care children's hospital from May 1996 to April 2007 were retrospectively reviewed. Patient demographics, premortem physiology, and end-of-life circumstances were recorded and compared with basic criteria for potential organ donation. A sensitivity analysis was performed to examine the effect of more strict physiologic and time criteria as well as 3 different rates of consent for donation. RESULTS: There were 1389 deaths during 11 years; 634 children (46%) underwent withdrawal of life support, of whom 518 had complete data and were analyzed. There were 131 children (25% of those withdrawn, 9% of all deaths) who met basic physiologic and time criteria for organ donation (80 kidney; 107 liver). Consideration of consent rates in sensitivity analysis resulted in an estimated 24 to 85 organ donors, an increase of 28% to 99% over the 86 actual brain-dead donors during the same time period. Assuming historical rates of organ recovery, these DCD donors might have produced 30 to 88 additional kidneys and 8 to 56 additional livers, an increase of 21% to 60% in kidney donation and 13% to 80% in livers above the number of organs recovered from brain-dead donors. CONCLUSIONS: Although relatively few children may have been eligible for DCD, they might have increased the number of organ donors from our institution, depending greatly on consent rates. DCD merits additional discussion and exploration.