Assessment of Actual Pediatric Organ Donation

Potential Neurological and Circulatory Determination of

Death

Erin E Bennett MD MPH

Jill Sweney MD

Cecile Aguayo RN

Craig Myrick RN

Armand H Matheny Antommaria MD PhD

Susan L Bratton MD MPH

Thank You

bull Jill Sweney MDbull Cecile Aguayo RNbull Craig Myrick RNbull Armand Matheny Antommaria MD PhDbull Susan Bratton MD MPH

Thank You

bull Jill Sweney MDbull Cecile Aguayo RNbull Craig Myrick RNbull Armand Matheny Antommaria MD PhDbull Susan Bratton MD MPH

Background for Organ Donation

bull Widening gap between organs needed and those availablebull gt 1900 children on the waitlist bull 15 of grafts

bull Infants have the highest waitlist mortalitybull Receive 65 of donor organs bull Donate 105 of organs

Waitlist Deaths by Age 2013

lt 1 year

1-5 yr

6-10 yr

11-17 yr

18-34 yr

35-49 yr

50-64 yr

0 5 10 15 20 25 30 35 40 45

Bratton SL ldquoThe Gift of Donation Pediatric Focusrdquo 2013

Foundation for Organ Donation

bull Dead Donor Rule vital organs can only be removed after a person is dead

bull Declaration of Death Irreversible cessation of eitherbull Circulatory and respiratory functions

or

bull Entire brain functions

Donation after Circulatory Determination of Death (DCDD)

bull Pulselessness apnea and unresponsiveness for 2 minutes

bull Consider after irreversible cessation of cardiorespiratory function

bull Increases abdominal organs for transplantation

Objectives

bull Assess potential for DCDD among pediatric patients having planned withdrawal of life support

bull Determine factors associated with potential candidates

bull Calculate conversion rates of donors who experience rapid circulatory and neurologic deaths

bull Intermountain Donor Services (organ procurement organization)bull Tracked all ICU patients dying on a ventilator from 2011-2012bull Evaluated eligibility

bull Evaluated difference eligible vs ineligible donors in an ICUbull Demographicsbull Clinical featuresbull Mode of death

Methods

Methods

bull To ultimately qualify DCDD candidates had to expire withinbull 60 minutes for kidney donationbull 20 minutes for liver donationbull Did not meet exclusion criteria

Results

bull 224 deaths in 2 yearsbull NICU N=81 median age 04 monthsbull CICU N=23 median age 42 monthsbull PICU N=120 median age 432 months

Resultsbull Potential Donors after Neurologic Death (N=23)bull All died in the PICUbull Median age 5 years oldbull Median number of ICU days 1bull Medical exclusions 0bull Parental refusal 4bull Neurological donors 18bull Conversion rate 78 (organs donated N=63)

Results

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

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Waitlist Deaths by Age 2013

lt 1 year

1-5 yr

6-10 yr

11-17 yr

18-34 yr

35-49 yr

50-64 yr

0 5 10 15 20 25 30 35 40 45

Bratton SL ldquoThe Gift of Donation Pediatric Focusrdquo 2013

Foundation for Organ Donation

bull Dead Donor Rule vital organs can only be removed after a person is dead

bull Declaration of Death Irreversible cessation of eitherbull Circulatory and respiratory functions

or

bull Entire brain functions

Donation after Circulatory Determination of Death (DCDD)

bull Pulselessness apnea and unresponsiveness for 2 minutes

bull Consider after irreversible cessation of cardiorespiratory function

bull Increases abdominal organs for transplantation

Objectives

bull Assess potential for DCDD among pediatric patients having planned withdrawal of life support

bull Determine factors associated with potential candidates

bull Calculate conversion rates of donors who experience rapid circulatory and neurologic deaths

bull Intermountain Donor Services (organ procurement organization)bull Tracked all ICU patients dying on a ventilator from 2011-2012bull Evaluated eligibility

bull Evaluated difference eligible vs ineligible donors in an ICUbull Demographicsbull Clinical featuresbull Mode of death

Methods

Methods

bull To ultimately qualify DCDD candidates had to expire withinbull 60 minutes for kidney donationbull 20 minutes for liver donationbull Did not meet exclusion criteria

Results

bull 224 deaths in 2 yearsbull NICU N=81 median age 04 monthsbull CICU N=23 median age 42 monthsbull PICU N=120 median age 432 months

Resultsbull Potential Donors after Neurologic Death (N=23)bull All died in the PICUbull Median age 5 years oldbull Median number of ICU days 1bull Medical exclusions 0bull Parental refusal 4bull Neurological donors 18bull Conversion rate 78 (organs donated N=63)

Results

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

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Foundation for Organ Donation

bull Dead Donor Rule vital organs can only be removed after a person is dead

bull Declaration of Death Irreversible cessation of eitherbull Circulatory and respiratory functions

or

bull Entire brain functions

Donation after Circulatory Determination of Death (DCDD)

bull Pulselessness apnea and unresponsiveness for 2 minutes

bull Consider after irreversible cessation of cardiorespiratory function

bull Increases abdominal organs for transplantation

Objectives

bull Assess potential for DCDD among pediatric patients having planned withdrawal of life support

bull Determine factors associated with potential candidates

bull Calculate conversion rates of donors who experience rapid circulatory and neurologic deaths

bull Intermountain Donor Services (organ procurement organization)bull Tracked all ICU patients dying on a ventilator from 2011-2012bull Evaluated eligibility

bull Evaluated difference eligible vs ineligible donors in an ICUbull Demographicsbull Clinical featuresbull Mode of death

Methods

Methods

bull To ultimately qualify DCDD candidates had to expire withinbull 60 minutes for kidney donationbull 20 minutes for liver donationbull Did not meet exclusion criteria

Results

bull 224 deaths in 2 yearsbull NICU N=81 median age 04 monthsbull CICU N=23 median age 42 monthsbull PICU N=120 median age 432 months

Resultsbull Potential Donors after Neurologic Death (N=23)bull All died in the PICUbull Median age 5 years oldbull Median number of ICU days 1bull Medical exclusions 0bull Parental refusal 4bull Neurological donors 18bull Conversion rate 78 (organs donated N=63)

Results

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

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Donation after Circulatory Determination of Death (DCDD)

bull Pulselessness apnea and unresponsiveness for 2 minutes

bull Consider after irreversible cessation of cardiorespiratory function

bull Increases abdominal organs for transplantation

Objectives

bull Assess potential for DCDD among pediatric patients having planned withdrawal of life support

bull Determine factors associated with potential candidates

bull Calculate conversion rates of donors who experience rapid circulatory and neurologic deaths

bull Intermountain Donor Services (organ procurement organization)bull Tracked all ICU patients dying on a ventilator from 2011-2012bull Evaluated eligibility

bull Evaluated difference eligible vs ineligible donors in an ICUbull Demographicsbull Clinical featuresbull Mode of death

Methods

Methods

bull To ultimately qualify DCDD candidates had to expire withinbull 60 minutes for kidney donationbull 20 minutes for liver donationbull Did not meet exclusion criteria

Results

bull 224 deaths in 2 yearsbull NICU N=81 median age 04 monthsbull CICU N=23 median age 42 monthsbull PICU N=120 median age 432 months

Resultsbull Potential Donors after Neurologic Death (N=23)bull All died in the PICUbull Median age 5 years oldbull Median number of ICU days 1bull Medical exclusions 0bull Parental refusal 4bull Neurological donors 18bull Conversion rate 78 (organs donated N=63)

Results

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

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Objectives

bull Assess potential for DCDD among pediatric patients having planned withdrawal of life support

bull Determine factors associated with potential candidates

bull Calculate conversion rates of donors who experience rapid circulatory and neurologic deaths

bull Intermountain Donor Services (organ procurement organization)bull Tracked all ICU patients dying on a ventilator from 2011-2012bull Evaluated eligibility

bull Evaluated difference eligible vs ineligible donors in an ICUbull Demographicsbull Clinical featuresbull Mode of death

Methods

Methods

bull To ultimately qualify DCDD candidates had to expire withinbull 60 minutes for kidney donationbull 20 minutes for liver donationbull Did not meet exclusion criteria

Results

bull 224 deaths in 2 yearsbull NICU N=81 median age 04 monthsbull CICU N=23 median age 42 monthsbull PICU N=120 median age 432 months

Resultsbull Potential Donors after Neurologic Death (N=23)bull All died in the PICUbull Median age 5 years oldbull Median number of ICU days 1bull Medical exclusions 0bull Parental refusal 4bull Neurological donors 18bull Conversion rate 78 (organs donated N=63)

Results

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

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

bull Intermountain Donor Services (organ procurement organization)bull Tracked all ICU patients dying on a ventilator from 2011-2012bull Evaluated eligibility

bull Evaluated difference eligible vs ineligible donors in an ICUbull Demographicsbull Clinical featuresbull Mode of death

Methods

Methods

bull To ultimately qualify DCDD candidates had to expire withinbull 60 minutes for kidney donationbull 20 minutes for liver donationbull Did not meet exclusion criteria

Results

bull 224 deaths in 2 yearsbull NICU N=81 median age 04 monthsbull CICU N=23 median age 42 monthsbull PICU N=120 median age 432 months

Resultsbull Potential Donors after Neurologic Death (N=23)bull All died in the PICUbull Median age 5 years oldbull Median number of ICU days 1bull Medical exclusions 0bull Parental refusal 4bull Neurological donors 18bull Conversion rate 78 (organs donated N=63)

Results

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

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Methods

bull To ultimately qualify DCDD candidates had to expire withinbull 60 minutes for kidney donationbull 20 minutes for liver donationbull Did not meet exclusion criteria

Results

bull 224 deaths in 2 yearsbull NICU N=81 median age 04 monthsbull CICU N=23 median age 42 monthsbull PICU N=120 median age 432 months

Resultsbull Potential Donors after Neurologic Death (N=23)bull All died in the PICUbull Median age 5 years oldbull Median number of ICU days 1bull Medical exclusions 0bull Parental refusal 4bull Neurological donors 18bull Conversion rate 78 (organs donated N=63)

Results

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

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Results

bull 224 deaths in 2 yearsbull NICU N=81 median age 04 monthsbull CICU N=23 median age 42 monthsbull PICU N=120 median age 432 months

Resultsbull Potential Donors after Neurologic Death (N=23)bull All died in the PICUbull Median age 5 years oldbull Median number of ICU days 1bull Medical exclusions 0bull Parental refusal 4bull Neurological donors 18bull Conversion rate 78 (organs donated N=63)

Results

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

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Resultsbull Potential Donors after Neurologic Death (N=23)bull All died in the PICUbull Median age 5 years oldbull Median number of ICU days 1bull Medical exclusions 0bull Parental refusal 4bull Neurological donors 18bull Conversion rate 78 (organs donated N=63)

Results

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

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Results

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

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Results

bull Time Measurements for Potential DCDD Donorsbull Time to death lt 1 month vs gt 1 month (median 42 min vs 12 min p=

002)bull No patients lt 1 month old died within 20 minutes (0 vs 50 p=0003)bull 33 of donors were lt 1 month oldbull 36 (23) were not referred prior to death but were all judged ineligible

by the OPObull DCDD organs donated included en bloc kidneys (n=7) single kidneys

(n=17) livers (n=2) organs for research (n=4)

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Patients Dying After Withdrawal of Life Support

0-7 days 1 week -1 month 1 month-1 year 1-3 years 4-9 years gt10 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 aUnstable 1 (4) 0 1 (3) 0 0 0Infection 7 (31) 9 (53) 14 (40) 0 1 (8) 7 (33) Malignancy 1 (4) 0 0 1 (10) 1 (8) 4 (19) Childrsquos weight lt 2 kg 4 (17) 4 (23) 4 (11) 0 0 0Organ dysfunction 3 (13) 1 (6) 2 (6) 1 (10) 1 (8) 0Genetic syndrome 3 (13) 0 1 (3) 1 (10) 1 (8) 0Total 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 2All times to death after extubation (minutes)

41 44 29 38 - 5 10 10 2 14 9 13 13

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Conclusionsbull DCDD increased pediatric organ donors by 67 and donated organs

by 48

bull Barriers included bull Missed referralsbull Inability to place small organsbull Family decline

bull Conversion rate DCDD is only determined in hindsight

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

Conclusions

bull Pediatric DCDD increases organ donation

bull Acceptability may be limited bybull Small patient organ sizebull Inability to accurately predict death in lt 1 hour

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966

References1 Organ Procurement and Transplantation Network National data US Department of Health and Human Services Available at httpoptntransplanthrsagovconvergelatestDatastep2asp

Accessed December 10 2014

2 Childress JF Baily MA Bonnie RJ et al Institute of Medicine Organ Donation Opportunities for Action Available at httpwwwiomeduReports2006Organ-Donation-Opportunities-for-Actionaspx Accessed December 10 2014

3 Robertson JA The dead donor rule Hastings Cent Rep 1999 296-14

4 Dominguez-Gil B Haase-Kromwijk B Van Leiden H Current situations in donation after circulatory death in European countries Transpl Int 2011 24676-686

5 Boucek MM Mashburn C Dunn SM et al Pediatric heart transplantation after declaration of cardiocirculatory death N Engl J Med 2008 14 359(7)709-714

6 Naim M Hoehn K Hasz R et al The Childrenrsquos Hospital of Philadelphiarsquos experience with donation after cardiac death Crit Care Med 2008 36(6)1729-1733

7 Koogler T Costarino AT The potential benefits of the pediatric nonheartbeating organ donor Pediatrics 1998 101(6)1049-1052

8 Charles E Scales A Brierley J The potential for neonatal organ donation in a childrenrsquos hospital Arch Dis Child Fetal Neonat Ed 2014 99(3)F225-229

9 Nakagawa TA Ashwal S Mathur M Mysore M Clinical reportmdashGuidelines for the determination of brain death in infants and children an update of the 1987 task force recommendations Pediatrics 2011128(3)e720-740

10 Pleacher KM Roach ES Van der Werf W Antommaria AHM Bratton SL Impact of a pediatric donation after cardiac death program Ped Crit Care Med 2009 10(2) 166-170

11 Institute for Healthcare Improvement Improvement Stories Organ Donation Collaborative Available at httpwwwihiorgresourcesPagesImprovementStoriesOrganDonationBreakthroughCollaborativeaspx Accessed January 9 2015

12 CMS Manual Publication 100-07 State Operation Provider Certification Department of Health and Human Services Centers for Medicare and Medicaid (CMS) Available at httpswwwcmsgovRegulations-and-GuidanceGuidanceTransmittalsdownloadsR37SOMApdf Accessed December 12 2014

13 Burns J Sellers D Meyer R Lewis-Newby M Truog R Epidemiology of death in the PICU at five US teaching hospitals Crit Care Med 2014 42 (9)2101-2108

14 Fraser J Thomas I Fish R et al The potential for non-heart beating organ donation within a paediatric intensive care unit Arch Dis Child 2011 (96)932-935

15 Shore PM Huang R Roy L et al Potential for liver and kidney donation after circulatory death in infants and children Pediatrics 2011128(3)e631-638

16 Saha Shttpfnbmjcomezproxylibutaheducontent991F59fullsid=2d3cd446-51bb-4d35-bcc8-aed0ed66744c - aff-1 Kent AL Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation Arch Dis Child Fetal Neonatal Ed 2014 99F59-F63

17 Labrecque M Parad R Gupta M Hansen A Donation after cardiac death The potential contribution of an infant organ donor population J Pediatr 2011 158(1)31-36

18 Hanley H Kim S Willey E Castleberry D Mathur M Identifying potential kidney donors among newborns undergoing circulatory determination of death Pediatrics 2014 133(1)e82-e87

19 Ledinh H Weekers L Bonvoisin C Results of cardio-circulatory death A single center experience Transpl Int 2012 25(2)201-209

20 Heran MK Heran NS Shemie SD A review of ancillary tests in evaluating brain death Can J Neurol Sci 2008 35(4)409-414

21 Shemie S Baker A Knoll G et al National recommendations for donation after cardiocirculatory death in Canada CMAJ 2006 175S1-S24

22 Bernat J DrsquoAlessandro A Port F Report of a national conference on donation after cardiac death Am J Transplant 2006 6(2)281-291

23 Ethics Committee American College of Critical Care Medicine Society of Critical Care Medicine Recommendations for nonheartbeating organ donation Crit Care Med 2001 29(9) 1826-1831

24 Health Care at the Crossroads Strategies for Narrowing the Organ Donation Gap and Protecting Patients Available at httpwwwjointcommissionorgOrgan_Donation Accessed January 27 2013

25 Arbus G Rochon J Thompson D Survival of cadaveric renal transplant grafts from young donors and in young recipients Pediatr Nephrol 1991 5(1)152-157

26 Harmon W Alexander S Tejani A Stablein D The effect of donor age on graft survival in pediatric cadaver renal transplant recipients a Report of the North American Pediatric Renal Transplant Cooperative Study Transplantation 1992 54(2)232-237

27 US Department of Health and Human Services Organ Procurement and Transplantation Network The revised national kidney allocation system is now in place Available at httpwwwunosorgsearchindexphpq=kidney+allocation+policyampx=0ampy=0 Accessed December 29 2014

28 Hoover S Bratton S Roach E Olson L Parental experiences and recommendations in donation after circulatory determination of death Pediatr Crit Care Med 2014 15(2) 105-111

29 Workman J Myrick C Meyers R Bratton S Nakagawa T Pediatric organ donation and transplantation Pediatrics 2013 131(6)e1723-e1730

30 Mazor R Baden HP Trends in pediatric organ donation after cardiac death Pediatrics 2007 120(4)e960-966