Prediction of death in adults–an educated guess in DCDs

Maria C. Nauman RRT, CPTCResource Triage Coordinator

California Transplant Donor Network

Objective

• Why we needed to change our practice• Describe how we changed our practice• Review our process for DCDs• Review some of the challenges of the tool• 2014 Data

Why change our method?

• Not reaching our goal of 10% DCD cases• More Objective• Article on predicting death–Dr Alan Yee, Neurologist, CPMC–Probability Tool

• 2012 initiated changes to our practice

Factors influencing time to death after withdrawal of life support in neurocritical patientsA.H. Yee, A.A. Rabinstein, P. Thama, et al. Neurology 2010; 74; 1380

• Retrospective study (2002-2008) Neuro ICU• 149 pts• Compared those who died <60 and >60• Excluding those who were declared BD, not

intubated, or had insufficient data• Correlation associated with earlier death after

withdrawal of life sustaining measures– Absent corneals, cough, extension, O2 index <4.2

Probability Tool

1. Enter FiO2, MAP, and PaO2 to generate oxygenation index.

FiO2 Mean Airway Pressure PaO2 Oxygenation Index

Oxygenation index:

http://www-users.med.cornell.edu/~spon/picu/calc/oxyindex.htm

2. Enter Y or N as appropriate to generate probability.

Corneal reflex? Cough reflex? Motor response 3-6?

Oxygenation index >4.2? Probability

Y = Yes 1 - No motor response

N = No 2 - Decerebrate posturing/extension

3 - Decorticate posturing/flexion

4 - Withdrawal

5 - Localizes

6 - Obeys commands

Monthly Review

Decision

Huddle

Evaluation Tool

Review

Referral

History

Diagnostics

SBTs

Clinical picture

Labs

Vent

Respiratory status

2014 Data

Score Cases Accuracy

<70 37 89%

70-80 14 57%

>80 18 87.5%

Problems

• How to score when the reflex is intermittent• How to score when we have to assess by phone• Assessments such as NIF and leak test – Equipment not available for NIF– Technique dependent

• Not having updated clinical information– ABGs, diagnostics

• It’s still an educated guess!

Questions?