Death and Ultrasound Evidence of the Akinetic Heart in Pediatric Cardiac Arrest.

Point-of-care ultrasound (POCUS) is an expanding noninvasive diagnostic modality used for the management of patients in multiple intensive care and pediatric specialties. POCUS is used to assess cardiac activity and pathology, pulmonary disease, intravascular volume status, intra-abdominal processes, procedural guidance including vascular access, lumbar puncture, thoracentesis, paracentesis, and pericardiocentesis. POCUS has also been used to determine anterograde flow following circulatory arrest when organ donation after circulatory death is being considered. Published guidelines exist from multiple medical societies including the recent guidelines for the use of POCUS in neonatology for diagnostic and procedural purposes.

Pediatric asthma severity scores distinguish suitable inpatient level of care for children admitted for status asthmaticus.

Objective: To determine if the Pediatric Asthma Severity Score (PASS) can distinguish "late-rescues" (transfer to the pediatric intensive care unit [PICU] within 24-hours of general pediatric floor admission), "PICU readmissions" (readmission within 24-h after transfer to a lower inpatient level of care), and unplanned 30-day hospital readmission in children admitted with status asthmaticus.Methods: We performed a single center, retrospective cohort study in 328 children admitted for asthma exacerbation aged 5-18 years from May 2015 to October 2017. We sought to determine if PASS values preceding admission from the emergency department or transfer to the general pediatric unit will be greater in children with late rescues and PICU readmissions and if a cutoff PASS values exist to discriminate these events prior to intrafacility transfer.Results: Nine (5%) late-rescues and 5 (3%) PICU readmissions accounted for 14/328 (4%) composite outcomes. PASS values were greater in children with these events (8 [IQR:5-8] vs. 5 [IQR:3-6], p < .01). Logistic regression of PASS on composite outcome yielded an odds ratio of 1.4 (1.1-1.8, p < .01) and ROC curve of PASS on a composite outcome yielded an AUC of 0.74 (0.61-0.87) with a threshold of ≥ 9. Nine (3%) children experienced unplanned 30-day hospital readmissions but PASS preceding hospital discharge was neither discriminative nor associated with hospital readmission.Conclusions: PASS values ≥ 9 identify children at increased risk for late-rescue and PICU readmission. Applied with traditionally criteria for selection of inpatient level of care, PASS may assist providers in reducing acute inpatient disposition errors.

Percutaneous Endoscopic Gastrostomy Enhances Interstage Growth in Infants With Hypoplastic Left Heart Syndrome.

OBJECTIVES: Infants with hypoplastic left heart syndrome undergoing staged palliation commonly experience chronic growth failure and malnutrition. Greater patient weight at stage 2 palliation (Glenn) is thought to be associated with improved perioperative outcomes. We aimed to compare weight for age z score and interstage growth velocity in children with and without a percutaneous endoscopic gastrostomy prior to Glenn and hypothesize that those with a percutaneous endoscopic gastrostomy experience-enhanced interstage growth and reduced malnutrition rates. DESIGN: Single-center, retrospective cohort study. SETTING: A total of 259-bed, quaternary, pediatric referral center. PATIENTS: Infants with hypoplastic left heart syndrome from 2007 to 2016 with and without percutaneous endoscopic gastrostomy insertion after initial palliation (Norwood). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were weight for age z score (at birth, Norwood, Norwood discharge, and Glenn), interstage growth velocity, and moderate-to-severe malnutrition (weight for age z score<-2) rates. Secondary outcomes were lengths of stay, mechanical ventilation rates after Glenn, and mortality. Statistical analyses included chi-square, Wilcoxon rank-sum, student's t, paired testing, and exploratory logistic regression. Of the 69 infants studied, 47 (68%) had percutaneous endoscopic gastrostomy insertion at a median of 156 (interquartile range, 115-158) days prior to Glenn. Among children with and without percutaneous endoscopic gastrostomy, we observed no differences in demographics, comorbidities, cardiothoracic surgical times, postoperative Glenn outcomes (length of stay, mechanical ventilation rate, peak 24-hr lactate, nitric oxide use, extracorporeal life support rate, or mortality), weight for age z score at birth, and weight for age z score at Norwood. At the time of percutaneous endoscopic gastrostomy insertion, weight for age z score was -2.5 ± 1.3 and subsequent growth velocity increased from 8 ± 7 to 40 ± 59 g/d (p < 0.01). From Norwood discharge to the date of Glenn, weight for age z score increased in infants with percutaneous endoscopic gastrostomy (-2.5 ± 1.1 to -1.5 ± 1.4 [p < 0.01]) with a large reduction in moderate-to-severe malnutrition rates (76-36%; p < 0.01). In general, weight for age z score at the time of Glenn was associated with reduced postoperative mortality (odds ratio, 0.3; 95% CI, 0.09-0.95; p = 0.04). CONCLUSIONS: Infants undergoing palliation for hypoplastic left heart syndrome with percutaneous endoscopic gastrostomy insertion prior to Glenn had improved growth velocity and dramatically reduced rates of moderate-to-severe malnutrition rates (40% reduction). In addition, we noted weight for age z score at when Glenn was associated with improved postoperative Glenn survival. No complications from percutaneous endoscopic gastrostomy were noted. Placement of a percutaneous endoscopic gastrostomy improved weight for age z score, enhanced interstage growth, and reduced malnutrition rates for this at-risk population of malnourished children.

Stress ulcer prophylaxis in children with status asthmaticus receiving systemic corticosteroids: a descriptive study assessing frequency of clinically important bleeding.

Objective: To determine the frequency of clinically important bleeding (CIB) among children hospitalized for status asthmaticus with and without exposure to stress ulcer prophylaxis (SUP).Methods: We performed a single-center, retrospective cohort in 217 children admitted for asthma exacerbation aged 5-18 years from May 2015 to May 2017. We assessed cohorts with and without exposure to SUP to determine if differences in frequency of CIB exist. Study outcomes included frequency of CIB, gastrointestinal complications (occult bleeding, macroscopic bleeding, gastric perforation, and acquired gastritis), and SUP-related adverse events (ventilator associated pneumonia, C. difficile colitis, necrotizing enterocolitis, and acute thrombocytopenia).Results: Ninety-two (42%) children received SUP of which 82 were admitted to the pediatric intensive care unit (PICU). There were no differences in asthma severity or known risk factors for CIB in children with and without SUP in the PICU subcohort. We observed no CIB or SUP-related adverse events. Two subjects acquired gastritis in the no-SUP cohort and one additional subject experienced occult gastrointestinal bleeding with spontaneous symptom resolution.Conclusion: Children admitted for status asthmaticus with and without SUP had no observed incidence of CIB. In this specific population, we propose a prerequisite assessment for the presence of known stress ulcer related gastrointestinal bleeding risk factors prior to the blanket administration of SUP.

Transcutaneous Carbon Dioxide Monitoring During Apnea Testing for Determination of Neurologic Death in Children: A Retrospective Case Series.

OBJECTIVES: Determination of neurologic death in children is a clinical diagnosis based on absence of neurologic function with irreversible coma and apnea. Apnea testing during determination of neurologic death assesses spontaneous respiration when PaCO2 increases to greater than or equal to 60 and greater than or equal to 20 mm Hg above pre-apneic baseline. The utility of transcutaneous carbon dioxide measurements during apnea testing in children is unknown. We seek to determine the degree of correlation between paired transcutaneous carbon dioxide and PaCO2 values during apnea testing for determination of neurologic death. DESIGN: Single-center, retrospective case series. SETTING: Twenty-eight bed PICU in a 259-bed, tertiary care, referral center. PATIENTS: Children 0-18 years old undergoing determination of neurologic death between May 2017 and December 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were paired transcutaneous carbon dioxide and PaCO2 values obtained during determination of neurologic death. Primary analyses included Pearson correlation coefficient, Bland-Altman bias and limits of agreement, and comparative statistics. Descriptive data included demographics, admission diagnoses, hemodynamics, Vasoactive Inotropic Scores, and arterial blood gas measurement. Eight children underwent 15 determination of neurologic death examinations resulting in 31 paired transcutaneous carbon dioxide and PaCO2 values for study. Transcutaneous carbon dioxide and PaCO2 correlated well (r = 0.94; p < 0.01). Bias between transcutaneous carbon dioxide and PaCO2 was -3.29 ± 7.14 mm Hg. Differences in means did not correlate with Vasoactive Inotropic Score (r = 0.2) or patient temperature (r = 0.11). Receiver operator characteristic curve of transcutaneous carbon dioxide after 3-10 minutes of apnea to discriminate positive apnea testing by the standard of PaCO2 yielded an area under the curve of 0.91 and threshold of greater than or equal to 64 mm Hg (sensitivity, 91.7%; specificity, 100%; positive predictive value, 100%; negative predictive value, 92.3%; accuracy, 95.9%). CONCLUSIONS: During apnea testing for determination of neurologic death in children, noninvasive transcutaneous carbon dioxide monitoring demonstrated high correlation, accuracy, and minimal bias when compared with PaCO2. Further validation is required before any recommendation to replace PaCO2 with noninvasive transcutaneous carbon dioxide monitoring can be proposed. However, concurrent transcutaneous carbon dioxide data may limit unnecessary apnea time and associated hemodynamic instability or respiratory decompensation by approximating goal arterial blood sampling to document target PaCO2.

Percutaneous Endoscopic Gastrostomy After Cardiothoracic Surgery in Children Less Than 2 Months Old: An Assessment of Long-Term Malnutrition Status and Gastrostomy Outcomes.

OBJECTIVES: Infants with critical congenital heart disease undergoing cardiothoracic surgery commonly experience chronic malnutrition and growth failure. We sought to determine whether placement of a percutaneous endoscopic gastrostomy was associated with reduced moderate-severe malnutrition status and to describe percutaneous endoscopic gastrostomy-related clinical and safety outcomes in this population. DESIGN: Single-center, retrospective cohort study. SETTING: Two hundred fifty-nine-bed, tertiary care, pediatric referral center. PATIENTS: Children with congenital heart disease less than 2 months old undergoing cardiothoracic surgery from 2007 to 2013 with and without percutaneous endoscopic gastrostomy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were weight for age z scores during hospitalization, at 6 months, and 1 year after cardiothoracic surgery. Secondary outcomes were frequency of percutaneous endoscopic gastrostomy revision, percutaneous endoscopic gastrostomy complications, and mortality. Statistical analyses included Wilcoxon rank-sum, Fisher exact, and Student t tests. Two hundred twenty-two subjects met study criteria, and 77 (35%) had percutaneous endoscopic gastrostomy placed at a mean of 45 ± 31 days after cardiothoracic surgery. No differences were noted for demographics, comorbidities, and weight for age z score at birth and at the time of cardiothoracic surgery. The percutaneous endoscopic gastrostomy cohort had greater Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery risk category (4 [4-5] vs 4 [2-4]) and length of stay (71 d [49-101 d] vs 26 d [15-42 d]). Mean weight for age z score at the time of percutaneous endoscopic gastrostomy was -2.8 ± 1.3. Frequency of moderate-severe malnutrition (weight for age z score, ≤ -2) was greater in children with percutaneous endoscopic gastrostomy at discharge (78% vs 48%), 6 months (61% vs 16%), and 1 year (41% vs 2%). Index mortality was lower in children with percutaneous endoscopic gastrostomy at 30 days (8% vs 0%) and hospital discharge (19% vs 4%). However, no mortality differences were observed after discharge. Growth velocity after percutaneous endoscopic gastrostomy was greater (44 ± 19 vs 10 ± 9 g/d). Children tolerated percutaneous endoscopic gastrostomy without hemodynamic compromise, minor percutaneous endoscopic gastrostomy complications, and anticipated percutaneous endoscopic gastrostomy revisions. Children without mortality had percutaneous endoscopic gastrostomy removal at a median duration of 253 days (133-545 d). Children with univentricular physiology had improved in-hospital mean growth velocity (6.3 vs 24.4 g/d; p < 0.01) and reduced 1-year rate moderate-severe malnutrition (66.7% vs 36.9%; p < 0.01) after percutaneous endoscopic gastrostomy placement. CONCLUSIONS: Percutaneous endoscopic gastrostomy placement was well tolerated and associated with improved postoperative growth velocity in children with critical congenital heart disease undergoing cardiothoracic surgery less than 2 months old. These findings were also noted in our subanalysis of children with univentricular physiology. Persistent rates of moderate-severe malnutrition were noted at 1-year follow-up. Although potential index mortality benefit was observed, definitive data are still needed.

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

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.

Development of a multinational registry of pediatric deceased organ donation activity.

BACKGROUND: There are no currently agreed upon international standards for reporting of pediatric deceased organ donation activity. This leads to difficulty in comparisons between jurisdictions for both researchers and policy stakeholders. The goal of this project was to develop and test a standardized registry for pediatric deceased donation activity. METHODS: Four countries (Canada, Spain, USA, and the UK) with geographical and practice diversity were approached to participate. Iterative exchanges were used to create data fields and definitions that were acceptable to all participants. Data from 2011 to 2015 (inclusive) were requested from national health databases and analyzed on a secure, web-based survey platform. RESULTS: Data were obtained from three of the four countries (Canada unable to provide). Total pediatric donation rates were stable over the 5-year period, but with variation between countries. pDCD rates were the most variable, representing 32.2% of total pediatric donation in the UK, 14.4% in the United States, and 2.6% in Spain during the studied period. Most organs from pediatric donors were allocated to adult recipients, though the rates of allocation of pediatric kidneys to pediatric recipients ranged from 7% in the United States to 40% in Spain. DISCUSSION: In this limited cohort of three countries, we demonstrated substantial variation in pediatric donation rates and practice. These data highlight opportunities for practice improvement such as the development of rigorous clinical practice guidelines. Future development of this registry will seek to engage more countries, and address barriers that prevented full participation of approached jurisdictions.

Transcutaneous carbon dioxide measurements in fruits, vegetables and humans: A prospective observational study.

BACKGROUND: Transcutaneous carbon dioxide measurement (TcCO2) is frequently used as a surrogate for arterial blood gas sampling in adults and children with critical illness. Data from noninvasive TcCO2 monitoring assists with clinical decisions regarding mechanical ventilation settings, estimation of metabolic consumption and determination of adequate end-organ tissue perfusion. OBJECTIVES: To report TcCO2 values obtained from various fruits, vegetables and elite critical care medicine specialists. DESIGN: Prospective, observational, nonblinded cohort study. SETTINGS: Single-centre, tertiary paediatric referral centre and organic farmers' market. PARTICIPANTS: Vegetables and fruits included 10 samples of each of the following: red delicious apple (Malus domestica), manzano banana (Musa sapientum), key lime (Citrus aurantiifolia), miniature sweet bell pepper (Capsicum annuum), sweet potato (Ipomoea batatas) and avocado (Persea americana). Ten human controls were studied including a paediatric intensivist, a paediatric inpatient hospital physician, four paediatric resident physicians and four paediatric critical care nurses. INTERVENTIONS: None. MAIN OUTCOME MEASURES: TcCO2 values for each species and device response times. RESULTS: TcCO2 readings were measurable in all study species except the sweet potato. Mean ±â€ŠSD values of TcCO2 for human controls [4.34 ±â€Š0.37 kPa (32.6 ±â€Š2.8 mmHg)] were greater than apples [3.09 ±â€Š0.19 kPa (23.2 ±â€Š1.4 mmHg), P < 0.01], bananas [2.73 ±â€Š0.28 kPa (20.5 ±â€Š2.1 mmHg), P < 0.01] and limes [2.76 ±â€Š0.52 kPa (20.7 ±â€Š3.9 mmHg), P < 0.01] but no different to those of avocados [4.29 ±â€Š0.44 kPa (32.2 ±â€Š3.3 mmHg), P = 0.77] and bell peppers [4.19 ±â€Š1.13 kPa (31.4 ±â€Š8.5 mmHg), P = 0.68]. Transcutaneous response times did not differ between research cohorts and human controls. CONCLUSION: We found nonroot, nontuberous vegetables to have TcCO2 values similar to that of healthy, human controls. Fruits yield TcCO2 readings, but substantially lower than human controls.

Organ Donation Following Neurologic and Circulatory Determination of Death.

OBJECTIVES: To describe important considerations during the process of caring for critically ill children who may be potential organ donors and supporting the family during the death of their child. DESIGN: Literature review and expert commentary. MEASUREMENT AND MAIN RESULTS: Medical literature focusing on pediatric donation, best pediatric donation practices, donor management, and factors influencing donation were reviewed. Additional pediatric data were obtained and reviewed from the U.S. Organ Procurement and Transplantation Network. Achieving successful organ donation requires the coordinated efforts of the critical care team, organ donation organization, and transplant team to effectively manage a potential donor and recover suitable organs for transplantation. Collaboration between these teams is essential to ensure that all potential organs are recovered in optimal condition, to reduce death and morbidity in children on transplantation waiting lists as well as fulfilling the family's wishes for their dying child to become a donor. CONCLUSIONS: Organ donation is an important component of end-of-life care and can help the healing process for families and medical staff following the death of a child. The process of pediatric organ donation requires healthcare providers to actively work to preserve the option of donation before the death of the child and ensure donation occurs after consent/authorization has been obtained from the family. Medical management of the pediatric organ donor requires the expertise of a multidisciplinary medical team skilled in the unique needs of caring for children after neurologic determination of death and those who become donors following circulatory death after withdrawal of life-sustaining medical therapies.

Standardization of Pediatric Interfacility Transport Handover: Measuring the Development of a Shared Mental Model.

OBJECTIVES: To determine if standardization of pediatric interfacility transport handover is associated with the development of a prototypical shared mental model between healthcare providers. DESIGN: A single center, prepost, retrospective cohort study. SETTINGS: A 259-bed, tertiary care, pediatric referral center. PATIENTS: Children 0 to 18 years old transferred to our critical care units or emergency center from October 2016 to February 2017. INTERVENTIONS: Standardization of interfacility handover using a multidisciplinary checklist, didactic teaching, and simulation conducted midway through the study period. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a shared mental model index defined as percent congruence among handover participants regarding key patient healthcare data including patient identification, diagnoses, transport interventions, immediate postadmission care plans, and anticipatory guidance for ongoing care. Secondary outcomes were handover comprehensiveness and teaming metrics such as efficiency, attendance, interruption frequency, and team member inclusion. During the study period, 100 transport handovers were observed of which 50 were preintervention and 50 post. A majority of handovers represented transfers to the emergency center (41%) or PICU (45%). There were no observable differences between prepost intervention cohorts by general characteristics, admission diagnoses, or severity of illness metrics including Pediatric Index of Mortality-3-Risk of Mortality, length of stay, mortality, frequency of invasive and noninvasive ventilation, and vasoactive use. The shared mental model index increased from 38% to 78% following standardization of handover. Attendance (76% vs 94%), punctuality (91.5% vs 98%), attention (82% vs 92%), summarization (42% vs 72%), and provision of anticipatory guidance (42% vs 58%) also improved. Efficiency was unchanged with a mean handover duration of 4 minutes in both cohorts. CONCLUSIONS: Considerable enhancements in handover quality, team participation, and the development of a shared mental model after standardization of interfacility transport handover were noted. These findings were achieved without compromising handover efficiency.

Time of Admission to the PICU and Mortality.

OBJECTIVES: To evaluate for any association between time of admission to the PICU and mortality. DESIGN: Retrospective cohort study of admissions to PICUs in the Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database from 2009 to 2014. SETTING: One hundred and twenty-nine PICUs in the United States. PATIENTS: Patients less than 18 years old admitted to participating PICUs; excluding those post cardiac bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 391,779 admissions were included with an observed PICU mortality of 2.31%. Overall mortality was highest for patients admitted from 07:00 to 07:59 (3.32%) and lowest for patients admitted from 14:00 to 14:59 (1.99%). The highest mortality on weekdays occurred for admissions from 08:00 to 08:59 (3.30%) and on weekends for admissions from 09:00 to 09:59 (4.66%). In multivariable regression, admission during the morning 06:00-09:59 and midday 10:00-13:59 were independently associated with PICU death when compared with the afternoon time period 14:00-17:59 (morning odds ratio, 1.15; 95% CI, 1.04-1.26; p = 0.006 and midday odds ratio, 1.09; 95% CI; 1.01-1.18; p = 0.03). When separated into weekday versus weekend admissions, only morning admissions were associated with increased odds of death on weekdays (odds ratio, 1.13; 95% CI, 1.01-1.27; p = 0.03), whereas weekend admissions during the morning (odds ratio, 1.33; 95% CI, 1.14-1.55; p = 0.004), midday (odds ratio, 1.27; 95% CI, 1.11-1.45; p = 0.0006), and afternoon (odds ratio, 1.17; 95% CI, 1.03-1.32; p = 0.01) were associated with increased risk of death when compared with weekday afternoons. CONCLUSIONS: Admission to the PICU during the morning period from 06:00 to 09:59 on weekdays and admission throughout the day on weekends (06:00-17:59) were independently associated with PICU death as compared to admission during weekday afternoons. Potential contributing factors deserving further study include handoffs of care, rounds, delays related to resource availability, or unrecognized patient deterioration prior to transfer.

Canadian Guidelines for Controlled Pediatric Donation After Circulatory Determination of Death-Summary Report.

OBJECTIVES: Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada. METHODS: We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners. RESULTS: We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report. CONCLUSIONS: This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation.

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement.

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.

Circulatory death determination in uncontrolled organ donors: a panel viewpoint.

One barrier for implementing programs of uncontrolled organ donation after the circulatory determination of death is the lack of consensus on the precise moment of death. Our panel was convened to study this question after we performed a similar analysis on the moment of death in controlled organ donation after the circulatory determination of death. We concluded that death could be determined by showing the permanent or irreversible cessation of circulation and respiration. Circulatory irreversibility may be presumed when optimal cardiopulmonary resuscitation efforts have failed to restore circulation and at least a 7-minute period has elapsed thereafter during which autoresuscitation to restored circulation could occur. We advise against the use of postmortem organ support technologies that reestablish circulation of warm oxygenated blood because of their risk of retroactively invalidating the required conditions on which death was declared.

Developing a standard method for apnea testing in the determination of brain death for patients on venoarterial extracorporeal membrane oxygenation: a pediatric case series.

OBJECTIVE: The revised guidelines for the determination of brain death in infants and children stress that apnea testing is an integral component in determining brain death based on clinical criteria. Unfortunately, these guidelines provide no process for apnea testing during the determination of brain death in patients supported on venoarterial extracorporeal membrane oxygenation. We review three pediatric patients supported on venoarterial extracorporeal membrane oxygenation who underwent apnea testing during their brain death evaluation. This is the only published report to elucidate a reliable, successful method for apnea testing in pediatric patients supported on venoarterial extracorporeal membrane oxygenation. DESIGN: Retrospective case series. SETTING: Two tertiary care PICUs in university teaching hospitals. PATIENTS: Three pediatric patients supported by venoarterial extracorporeal membrane oxygenation after cardiopulmonary arrest. INTERVENTIONS: After neurologic examinations demonstrated cessation of brain function in accordance with current pediatric brain death guidelines, apnea testing was performed on each child while supported on venoarterial extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS: In two of the three cases, the patients remained hemodynamically stable with normal oxygen saturations as venoarterial extracorporeal membrane oxygenation sweep gas was weaned and apnea testing was undertaken. Apnea testing demonstrating no respiratory effort was successfully completed in these two cases. The third patient became hemodynamically unstable, invalidating the apnea test. CONCLUSIONS: Apnea testing on venoarterial extracorporeal membrane oxygenation can be successfully undertaken in the evaluation of brain death. We provide a suggested protocol for apnea testing while on venoarterial extracorporeal membrane oxygenation that is consistent with the updated pediatric brain death guidelines. This is the only published report to elucidate a reliable, successful method for apnea testing in pediatric patients supported on venoarterial extracorporeal membrane oxygenation.

An official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: ethical and policy considerations in organ donation after circulatory determination of death.

RATIONALE: Donation after circulatory determination of death (DCDD) has the potential to increase the number of organs available for transplantation. Because consent and management of potential donors must occur before death, DCDD raises unique ethical and policy issues. OBJECTIVES: To develop an ethics and health policy statement on adult and pediatric DCDD relevant to critical care and transplantation stakeholders. METHODS: A multidisciplinary panel of stakeholders was convened to develop an ethics and health policy statement. The panel consisted of representatives from the American Thoracic Society, Society of Critical Care Medicine, International Society for Heart and Lung Transplantation, Association of Organ Procurement Organizations, and the United Network of Organ Sharing. The panel reviewed the literature, discussed important ethics and health policy considerations, and developed a guiding framework for decision making by stakeholders. RESULTS: A framework to guide ethics and health policy statement was established, which addressed the consent process, pre- and post mortem interventions, the determination of death, provisions of end-of-life care, and pediatric DCDD. CONCLUSIONS: The information presented in this Statement is based on the current evidence, experience, and clinical rationale. New clinical research and the development and dissemination of new technologies will eventually necessitate an update of this Statement.

Knowledge gaps in heart and lung donation after the circulatory determination of death: Report of a workshop of the National Heart, Lung, and Blood Institute.

In a workshop sponsored by the U.S. National Heart, Lung, and Blood Institute, experts identified current knowledge gaps and research opportunities in the scientific, conceptual, and ethical understanding of organ donation after the circulatory determination of death and its technologies. To minimize organ injury from warm ischemia and produce better recipient outcomes, innovative techniques to perfuse and oxygenate organs postmortem in situ, such as thoracoabdominal normothermic regional perfusion, are being implemented in several medical centers in the US and elsewhere. These technologies have improved organ outcomes but have raised ethical and legal questions. Re-establishing donor circulation postmortem can be viewed as invalidating the condition of permanent cessation of circulation on which the earlier death determination was made and clamping arch vessels to exclude brain circulation can be viewed as inducing brain death. Alternatively, TA-NRP can be viewed as localized in-situ organ perfusion, not whole-body resuscitation, that does not invalidate death determination. Further scientific, conceptual, and ethical studies, such as those identified in this workshop, can inform and help resolve controversies raised by this practice.