NEUROCRITICAL CARE Divining death-do we have the right tools for the job?
ABSTRACT Given the national deficit in available organs for transplantation, substantial motivation exists to enhance procurement in the area of donation after cardiac death. This article reviews a new predictive tool that aims to identify donors dying within the viable time frame while reducing the human and resource implications of unsuccessful attempts.
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ABSTRACT: Donation after cardiac death (DCD) is uncommon in part because clinicians cannot prospectively identify patients who are likely to die within 60 min of withdrawal of life-sustaining treatments (LST). UNOS criteria exist but have not been validated. Consecutive patients electively withdrawn from LST at five university-affiliated hospitals were prospectively enrolled. Demographic and treatment characteristics were collected. Chi-square was used to determine risk for death within 60 min and validate the UNOS criteria. A total of 533 patients were enrolled. A total of 28 were excluded from this report due to age <18 years or failure to include time of death. Of 505 (95%) patients, 227 (45%) died within 60 min, 134 (27%) in 1-6 h and 144 (29%) >6 h after withdrawal of LST. A total of 29%, 52%, 65% and 82% of patients with 0,1,2 and 3 UNOS DCD criteria, respectively, died within 60 min of withdrawal of LST. The data validate the UNOS criteria. Patients with no criteria might be excluded from consideration for DCD. Those with more than one criterion are reasonable candidates, while those with a single criterion should be considered if a 50% failure rate for DCD is acceptable.American Journal of Transplantation 02/2008; 8(2):432-41. DOI:10.1111/j.1600-6143.2007.02087.x · 6.19 Impact Factor
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ABSTRACT: Donation after cardiac death is a method by which severely neurologically injured patients not fulfilling brain-death criteria can donate organs. To develop an evaluation tool that can be used to predict if a patient is a suitable candidate for donation after cardiac death. The University of Wisconsin Donation After Cardiac Death Evaluation Tool assigns numeric values to observable clinical parameters to yield an overall predictive score of suitability for donation after cardiac death. This evaluation tool is typically utilized in a critical care unit to evaluate patients with a severe neurological injury, who do not meet brain-death criteria, and for whom the physician and family have chosen to terminally withdraw life support. Each patient is disconnected from a ventilator and observed for up to 10 minutes. Observations are then scored to yield a prediction of suitability for donation after cardiac death. Using the University of Wisconsin Donation After Cardiac Death Evaluation Tool, we were able to predict suitability for donation after cardiac death 83.7% of the time, within a 60-minute period and 74.4% of the time within a 120-minute period. The actual results using the tool were higher when clinical observations were included in the donation after cardiac death evaluation--an overall accuracy of 88.4%.Progress in transplantation (Aliso Viejo, Calif.) 01/2004; 13(4):265-73. · 0.69 Impact Factor
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ABSTRACT: Successful donation of organs after cardiac death (DCD) requires identification of patients who will die within 60 min of withdrawal of life-sustaining treatment (WLST). We aimed to validate a straightforward model to predict the likelihood of death within 60 min of WLST in patients with irreversible brain injury. In this multicentre, observational study, we prospectively enrolled consecutive comatose patients with irreversible brain injury undergoing WLST at six medical centres in the USA and the Netherlands. We assessed four clinical characteristics (corneal reflex, cough reflex, best motor response, and oxygenation index) as predictor variables, which were selected on the basis of previous findings. We excluded patients who had brain death or were not intubated. The primary endpoint was death within 60 min of WLST. We used univariate and multivariable logistic regression analyses to assess associations with predictor variables. Points attributed to each variable were summed to create a predictive score for cardiac death in patients in neurocritical state (the DCD-N score). We assessed performance of the score using area under the curve analysis. We included 178 patients, 82 (46%) of whom died within 60 min of WLST. Absent corneal reflexes (odds ratio [OR] 2·67, 95% CI 1·19-6·01; p=0·0173; 1 point), absent cough reflex (4·16, 1·79-9·70; p=0·0009; 2 points), extensor or absent motor responses (2·99, 1·22-7·34; p=0·0168; 1 point), and an oxygenation index score of more than 3·0 (2·31, 1·10-4·88; p=0·0276; 1 point) were predictive of death within 60 min of WLST. 59 of 82 patients who died within 60 min of WLST had DCD-N scores of 3 or more (72% sensitivity), and 75 of 96 of those who did not die within this interval had scores of 0-2 (78% specificity); taking into account the prevalence of death within 60 min in this population, a score of 3 or more was translated into a 74% chance of death within 60 min (positive predictive value) and a score of 0-2 translated into a 77% chance of survival beyond 60 min (negative predictive value). The DCD-N score can be used to predict potential candidates for DCD in patients with non-survivable brain injury. However, this score needs to be tested specifically in a cohort of potential donors participating in DCD protocols. None.The Lancet Neurology 04/2012; 11(5):414-9. DOI:10.1016/S1474-4422(12)70060-1 · 21.82 Impact Factor