Prediction of potential for organ donation after cardiac death in patients in neurocritical state: A prospective observational study

Alejandro A. Rabinstein, Alan H. Yee, Jay Mandrekar, Jennifer E. Fugate, Yorick J. de Groot, Erwin J O Kompanje, Lori A. Shutter, W. David Freeman, Michael A. Rubin, Eelco F M Wijdicks

Research output: Contribution to journalArticle

38 Citations (Scopus)

Abstract

Background: Successful donation of organs after cardiac death (DCD) requires identification of patients who will die within 60 min of withdrawal of life-sustaining treatment (WLST). We aimed to validate a straightforward model to predict the likelihood of death within 60 min of WLST in patients with irreversible brain injury. Methods: In this multicentre, observational study, we prospectively enrolled consecutive comatose patients with irreversible brain injury undergoing WLST at six medical centres in the USA and the Netherlands. We assessed four clinical characteristics (corneal reflex, cough reflex, best motor response, and oxygenation index) as predictor variables, which were selected on the basis of previous findings. We excluded patients who had brain death or were not intubated. The primary endpoint was death within 60 min of WLST. We used univariate and multivariable logistic regression analyses to assess associations with predictor variables. Points attributed to each variable were summed to create a predictive score for cardiac death in patients in neurocritical state (the DCD-N score). We assessed performance of the score using area under the curve analysis. Findings: We included 178 patients, 82 (46%) of whom died within 60 min of WLST. Absent corneal reflexes (odds ratio [OR] 2·67, 95% CI 1·19-6·01; p=0·0173; 1 point), absent cough reflex (4·16, 1·79-9·70; p=0·0009; 2 points), extensor or absent motor responses (2·99, 1·22-7·34; p=0·0168; 1 point), and an oxygenation index score of more than 3·0 (2·31, 1·10-4·88; p=0·0276; 1 point) were predictive of death within 60 min of WLST. 59 of 82 patients who died within 60 min of WLST had DCD-N scores of 3 or more (72% sensitivity), and 75 of 96 of those who did not die within this interval had scores of 0-2 (78% specificity); taking into account the prevalence of death within 60 min in this population, a score of 3 or more was translated into a 74% chance of death within 60 min (positive predictive value) and a score of 0-2 translated into a 77% chance of survival beyond 60 min (negative predictive value). Interpretation: The DCD-N score can be used to predict potential candidates for DCD in patients with non-survivable brain injury. However, this score needs to be tested specifically in a cohort of potential donors participating in DCD protocols. Funding: None.

Original languageEnglish (US)
Pages (from-to)414-419
Number of pages6
JournalThe Lancet Neurology
Volume11
Issue number5
DOIs
StatePublished - May 2012

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Tissue and Organ Procurement
Observational Studies
Prospective Studies
Brain Injuries
Abnormal Reflexes
Cough
Therapeutics
Blinking
Brain Death
Coma
Netherlands
Multicenter Studies
Area Under Curve
Reflex
dicarboxydine
Logistic Models
Odds Ratio
Regression Analysis
Tissue Donors
Survival

ASJC Scopus subject areas

  • Clinical Neurology

Cite this

Rabinstein, A. A., Yee, A. H., Mandrekar, J., Fugate, J. E., de Groot, Y. J., Kompanje, E. J. O., ... Wijdicks, E. F. M. (2012). Prediction of potential for organ donation after cardiac death in patients in neurocritical state: A prospective observational study. The Lancet Neurology, 11(5), 414-419. https://doi.org/10.1016/S1474-4422(12)70060-1

Prediction of potential for organ donation after cardiac death in patients in neurocritical state : A prospective observational study. / Rabinstein, Alejandro A.; Yee, Alan H.; Mandrekar, Jay; Fugate, Jennifer E.; de Groot, Yorick J.; Kompanje, Erwin J O; Shutter, Lori A.; Freeman, W. David; Rubin, Michael A.; Wijdicks, Eelco F M.

In: The Lancet Neurology, Vol. 11, No. 5, 05.2012, p. 414-419.

Research output: Contribution to journalArticle

Rabinstein, AA, Yee, AH, Mandrekar, J, Fugate, JE, de Groot, YJ, Kompanje, EJO, Shutter, LA, Freeman, WD, Rubin, MA & Wijdicks, EFM 2012, 'Prediction of potential for organ donation after cardiac death in patients in neurocritical state: A prospective observational study', The Lancet Neurology, vol. 11, no. 5, pp. 414-419. https://doi.org/10.1016/S1474-4422(12)70060-1
Rabinstein, Alejandro A. ; Yee, Alan H. ; Mandrekar, Jay ; Fugate, Jennifer E. ; de Groot, Yorick J. ; Kompanje, Erwin J O ; Shutter, Lori A. ; Freeman, W. David ; Rubin, Michael A. ; Wijdicks, Eelco F M. / Prediction of potential for organ donation after cardiac death in patients in neurocritical state : A prospective observational study. In: The Lancet Neurology. 2012 ; Vol. 11, No. 5. pp. 414-419.
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AU - Rabinstein, Alejandro A.

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AU - Fugate, Jennifer E.

AU - de Groot, Yorick J.

AU - Kompanje, Erwin J O

AU - Shutter, Lori A.

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N2 - Background: Successful donation of organs after cardiac death (DCD) requires identification of patients who will die within 60 min of withdrawal of life-sustaining treatment (WLST). We aimed to validate a straightforward model to predict the likelihood of death within 60 min of WLST in patients with irreversible brain injury. Methods: In this multicentre, observational study, we prospectively enrolled consecutive comatose patients with irreversible brain injury undergoing WLST at six medical centres in the USA and the Netherlands. We assessed four clinical characteristics (corneal reflex, cough reflex, best motor response, and oxygenation index) as predictor variables, which were selected on the basis of previous findings. We excluded patients who had brain death or were not intubated. The primary endpoint was death within 60 min of WLST. We used univariate and multivariable logistic regression analyses to assess associations with predictor variables. Points attributed to each variable were summed to create a predictive score for cardiac death in patients in neurocritical state (the DCD-N score). We assessed performance of the score using area under the curve analysis. Findings: We included 178 patients, 82 (46%) of whom died within 60 min of WLST. Absent corneal reflexes (odds ratio [OR] 2·67, 95% CI 1·19-6·01; p=0·0173; 1 point), absent cough reflex (4·16, 1·79-9·70; p=0·0009; 2 points), extensor or absent motor responses (2·99, 1·22-7·34; p=0·0168; 1 point), and an oxygenation index score of more than 3·0 (2·31, 1·10-4·88; p=0·0276; 1 point) were predictive of death within 60 min of WLST. 59 of 82 patients who died within 60 min of WLST had DCD-N scores of 3 or more (72% sensitivity), and 75 of 96 of those who did not die within this interval had scores of 0-2 (78% specificity); taking into account the prevalence of death within 60 min in this population, a score of 3 or more was translated into a 74% chance of death within 60 min (positive predictive value) and a score of 0-2 translated into a 77% chance of survival beyond 60 min (negative predictive value). Interpretation: The DCD-N score can be used to predict potential candidates for DCD in patients with non-survivable brain injury. However, this score needs to be tested specifically in a cohort of potential donors participating in DCD protocols. Funding: None.

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