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Neonatal Organ Donation Following Circulatory Death: What is the Potential?

Neonatal Organ Donation Following Circulatory Death: What is the Potential?. Justin Lambert Stiers MD , Neonatal-Perinatal Medicine Fellow, University of Utah Pediatrics, Primary Children's Cecile Aguayo BSN, RN , Dir. of Professional Ed./Hospital Services Intermountain Donor Services.

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Neonatal Organ Donation Following Circulatory Death: What is the Potential?

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  1. Neonatal Organ Donation Following Circulatory Death: What is the Potential? Justin Lambert Stiers MD, Neonatal-Perinatal Medicine Fellow, University of Utah Pediatrics, Primary Children's Cecile Aguayo BSN, RN, Dir. of Professional Ed./Hospital Services Intermountain Donor Services

  2. A Little About Us… • Designated for Utah; Southeastern Idaho; Western Wyoming; Elko, Nevada • 3.5 million • 87 hospitals (3 level 1 trauma centers) • 3 transplant centers; 12 Programs • 2013- 98 organ donors; 3.21 OTPD; 26% DCD; 82% conversion rate; 72% Utah Donor Designation

  3. Primary Children’s Hospital • Level I Trauma & Transplant Center • 289 licensed bed • 3 Intensive Care Units • Highest pediatric DCD donation rate in the nation • Repeat winner of the Silver Medal of Honor Award • April 1, 2012 to March 31, 2014 • Conversion Rate 83% • DCD Rate 37.5% • OTPD 2.83

  4. Question To Run On… What practices can I implement  to improve the pediatric and neonatal donation programs at my hospital?

  5. Outline • Identifying Opportunity • Study Design and Results • Old vs. Current Practice • Next Steps

  6. Opportunity Identified • November 4th, 2011- 1st Anencephaly Donor (1.9 kg) Logan Regional Medical Center • March 4th 2013: Dr. DiGeronimo (neonatologist) inquires the possibility of family donation counseling prenatally. • August 26th 2013: Prenatal Diagnosis Conference

  7. What does this mean… • The potential to offer these families optimal end-of-life care, with the option of donation. • Advocacy for a donor population that was generally excluded. What is the true donation potential for the neonates?

  8. Opportunities exist for organ donation in patients… • Weighing greater than 2 kg • Elective withdrawal of life sustaining interventions • Death occurs within 90 minutes We Speculated: Many, if not most, deaths in the NICU meet these criteria

  9. How many neonates in our NICU… • Meet eligibility criteria for organ donation at the time of death? • Go on to donate organs or tissue?

  10. Retrospective study of all neonates: • Admitted into Primary Children’s Hospital NICU between January 1st, 2010 and May 7th, 2013 – and – • Died prior to hospital discharge

  11. Regional Level 4 NICU • Pediatric Subspecialists • Pediatric Surgery • Cardiology • Neurology • Extracorporeal Membrane Oxygenation (ECMO) • Patient Population • Outborn Newborns – Utah, Wyoming, Colorado, Montana, Idaho, Nevada • Complications of prematurity • Complex congenital anomalies – including congenital heart disease • Diseases at birth – Sepsis, asphyxia, pneumonia, stroke…

  12. Primary Outcome • Theoretical eligibility for organ donation based on Intermountain Donor Services (IDS) DCD criteria

  13. DCD Criteria • Weight > 2kg • Warm Ischemic Time <90 minutes

  14. Secondary Outcomes • Cause of death • Organ donation status: • Eligible or ineligible • Reason for ineligibility (if applicable) • Organ and/or tissues donated

  15. Potentially Eligible Neonates (n=60) • Warm Ischemia Time: • Median 48 minutes • Range of 1 minute to 13 hours 15 minutes • Weight: • Median = 3.3 kg • Range = 2 kg – 7.34 kg

  16. OPO Referral Process • Contacted when the decision is made to withdraw/limit life sustaining interventions: • If weight is >2 kg - and - • Patient is requiring mechanical ventilation • IDS approaches family to discuss organ donation • If the family agrees, workup is initiated and case is presented to the transplant surgeon (Dr. Perez) for ultimate decision on donation potential

  17. In Summary • 44% of neonatal deaths in a regional, level-4 NICU were potentially eligible for donation • Only 1 in 5 potential neonatal organ donors were appropriately referred to the organ procurement organization for assessment ~1/3 of those appropriately referred went on to donate organs

  18. Conclusion A discrepancy exists between donor eligibility and actual organ donation in newborns Significant opportunity exists for improvement in end-of-life care for families with critically ill newborns

  19. Old Practice: • > 5 kgs BD or DCD • No discussion of organ donation to families prenatally. • New Practice: • > 2kgs BD or DCD. • Discussion of organ donation options to families prenatally if appropriate. • Physician Education: OB, MFM, Etc.

  20. IDS Pediatric Donors < 15 kg 2011- Present • 14 pediatric donors (< 15 kg) • 9 pediatric donors (≤5 kg) • 12 of the 14 donor from PCH • 3 of the 12 from NICU • 2 of the 14 referred prenatally • Anencephaly (1.9 kg) November 4th, 2011- Logan Regional Medical Center • Encephalocele (2.2 kg)- March 3rd, 2013- Jordan Valley Regional Medical Center • 16 organs transplanted

  21. Our Next Steps…

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