The 10th Annual Utah Health Services Research Conference: Assessment of Actual Pediatric Organ Donation Potential: Neurological and Circulatory Determination of Death. By: Erin E. Bennett, M.D., MPH; Jill Sweney, M.D.; Cecile Aguayo, R.N.; Craig Myrick, R.N.; Armand H. Matheny Antommaria, M.D., Ph.D.; Susan L. Bratton, M.D., MPH. Patient Centered Research Methods Core, University of Utah, CCTS

1. Assessment of Actual Pediatric
Organ Donation Potential:
Neurological and Circulatory
Determination of Death
Erin E. Bennett, M.D., MPH
Jill Sweney, M.D.
Cecile Aguayo, R.N.
Craig Myrick, R.N.
Armand H. Matheny Antommaria, M.D., Ph.D.
Susan L. Bratton, M.D, MPH

2. Thank You
• Jill Sweney, MD
• Cecile Aguayo, RN
• Craig Myrick, RN
• Armand Matheny Antommaria, MD, PhD
• Susan Bratton, MD, MPH

3. Background for Organ Donation
• Widening gap between organs needed and those available
• > 1,900 children on the waitlist
• 1.5% of grafts
• Infants have the highest waitlist mortality
• Receive 6.5% of donor organs
• Donate 10.5% of organs

4. Waitlist Deaths by Age 2013
0% 10% 20% 30% 40% 50%
< 1 year
1-5 yr
6-10 yr
11-17 yr
18-34 yr
35-49 yr
50-64 yr
Bratton, SL. “The Gift of Donation: Pediatric Focus.” 2013.

5. Foundation for Organ Donation
• Dead Donor Rule: vital organs can only be removed after a
person is dead
• Declaration of Death: Irreversible cessation of either
• Circulatory and respiratory functions
or
• Entire brain functions

6. Donation after Circulatory
Determination of Death (DCDD)
• Pulselessness, apnea, and unresponsiveness for 2 minutes
• Consider after irreversible cessation of cardiorespiratory function
• Increases abdominal organs for transplantation

7. Objectives
• Assess potential for DCDD among pediatric patients having planned
withdrawal of life support
• Determine factors associated with potential candidates
• Calculate conversion rates of donors who experience rapid
circulatory and neurologic deaths

8. • Intermountain Donor Services (organ procurement organization):
• Tracked all ICU patients dying on a ventilator from 2011-2012
• Evaluated eligibility
• Evaluated difference: eligible vs. ineligible donors in an ICU
• Demographics
• Clinical features
• Mode of death
Methods

9. Methods
• To ultimately qualify, DCDD candidates had to expire within:
• 60 minutes for kidney donation
• 20 minutes for liver donation
• Did not meet exclusion criteria

10. Results
• 224 deaths in 2 years:
• NICU: N=81, median age 0.4 months
• CICU: N=23, median age 4.2 months
• PICU: N=120, median age 43.2 months

11. Results
• Potential Donors after Neurologic Death (N=23)
• All died in the PICU
• Median age: 5 years old
• Median number of ICU days: 1
• Medical exclusions: 0
• Parental refusal: 4
• Neurological donors: 18
• Conversion rate: 78% (organs donated N=63)

12. Results
• Potential Donors after Circulatory Death (N=45)
• Medical exclusion: 73 (62% of 112 referred to OPO)
• Parental refusal: 33 (73% of 45 judged as eligible)
• 37 of 45 died within 1 hour of WLST (82%)
• Conversion rate: 27% or 32% among those dying < 1 hour WLST

13. Results
• Time Measurements for Potential DCDD Donors
• Time to death < 1 month vs. > 1 month (median 42 min vs. 12 min, p=
0.02)
• No patients < 1 month old died within 20 minutes (0 vs. 50%, p=0.003)
• 33% of donors were < 1 month old
• 36 (23%) were not referred prior to death but were all judged ineligible
by the OPO
• DCDD organs donated included: en bloc kidneys (n=7), single kidneys
(n=17), livers (n=2), organs for research (n=4)

14. Patients Dying After Withdrawal of Life Support
0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years >10 years
Total number WLST prior to
death
N=34 N=28 N=44 N=12 N=14 N=22
Missed referrals 11 (32%) 11 (39%) 9 (20%) 2 (17%) 2 (14%) 1 (5%)
Referred to OPO prior to
WLST
23 (68%) 17 (61%) 35 (80%) 10 (83%) 12 (86%) 21 (95%)
E x c l u s i o n C r i t e r i a
Unstable 1 (4%) 0 1 (3%) 0 0 0
Infection 7 (31%) 9 (53%) 14 (40%) 0 1 (8%) 7 (33%)
Malignancy 1 (4%) 0 0 1 (10%) 1 (8%) 4 (19%)
Child’s weight < 2 kg 4 (17%) 4 (23%) 4 (11%) 0 0 0
Organ dysfunction 3 (13%) 1 (6%) 2 (6%) 1 (10%) 1 (8%) 0
Genetic syndrome 3 (13%) 0 1 (3%) 1 (10%) 1 (8%) 0
Total Eligible for donation 4 3 13 7 8 10
Family refusal 2 (50%) 1 (33%) 13 (100%) 4 (57%) 6 (75%) 7 (70%)
Donors 2 (50%) 2 (67%) 0 3 (43%) 2 (25%) 3 (30%)
T i m e M e a s u r e m e n t s f o r A l l E l i g i b l e D o n o r s N = 4 5
Time to death after extubation
minutes (median, IQR)
41 (41, 46) 46 (29, -) 30 (1, 198) 12 (8, 111) 9 (3, 23) 12 (1, 258)
Death within 20 minutes* 0 0 6 (46%) 4 (57%) 6 (75%) 8 (80%)
Death within 60 minutest all
eligible donors
4 (100%) 2 (67%) 9 (69%) 5 (71%) 8 (100%) 9 (90%)
T i m e M e a s u r e m e n t s f o r A c t u a l D o n o r s N = 1 2
All times to death after extubation
(minutes)
41, 44 29, 38 - 5, 10, 10 2, 14 9, 13, 13

15. Conclusions
• DCDD increased pediatric organ donors by 67% and donated organs
by 48%
• Barriers included:
• Missed referrals
• Inability to place small organs
• Family decline
• Conversion rate DCDD is only determined in hindsight

16. Conclusions
• Pediatric DCDD increases organ donation
• Acceptability may be limited by:
• Small patient organ size
• Inability to accurately predict death in < 1 hour

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