(373) A Case of Pediatric Autoresuscitation Complicating Organ Donation After Cardiac Death

Introduction: Donation after circulatory death (DCD) refers to the retrieval of organs for the purpose of transplantation from patients whose death is pronounced and confirmed. Many centers do not have pediatric DCD policies, and there is variability in those that do exist.

Here we present a pediatric patient that developed autoresuscitation after declaration of cardiac death and during organ procurement. This case highlights the need for formal policies including time between declaration of cardiac death and organ procurement.

Description: A 13-month-old child was admitted to our pediatric ICU following prolonged cardiac arrest resulting in severe anoxic brain injury. Despite supportive care, she did not improve. Given her grave and unrecoverable prognosis, her family elected to donate her organs via DCD.

As per our institution’s protocol, the patient was transported to the perioperative area; the pediatric critical care medicine (PCCM) service directed her withdrawal of life-sustaining therapy and provision of comfort care. She was monitored with oximetry, ECG, and noninvasive blood pressure. After 18 minutes, she developed asystole, had undetectable pulses, and heart tones that could not be auscultated. Time of death was called after another 2 minutes, and her body was transported to the operating room for organ recovery. The PCCM service was notified that upon incision from the suprasternal notch to symphysis pubis, the patient developed a minimally perfusing cardiac rhythm and agonal breathing. The procedure was aborted, and she was transported back to the ICU for end-of-life care. She progressed to cardiac death 1 hour and 45 minutes later.

Discussion: Autoresuscitation, or delayed return of spontaneous circulation without assistance, is very rare. While the mean time to autoresuscitation after cessation of CPR in adults is ~4 minutes, it is prolonged in pediatrics.

Following this case, our institution placed a moratorium on pediatric DCD to review available literature and protocols of peer institutions, after which we extended the time from progression to asystole until the determination of cardiac death from 2 minutes to 5 minutes, at which point the patient would be transferred for organ procurement. This case emphasizes the need for a universal protocol for pediatric DCD.