Scientific Letter
Controlled asystole donation in the paediatric patient
Donación en asistolia controlada en el paciente pediátrico
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Donation after circulatory death is categorised based on the revised Maastricht classification (Paris 2013) into uncontrolled DCD, category I (dead on arrival, or sudden cardiac arrest without performance of cardiopulmonary resuscitation) and category II (sudden cardiac arrest with unsuccessful resuscitation) and controlled DCD, category III (awaiting circulatory death after withdrawal of life-sustaining therapies) and category IV (cardiac arrest in a brain-dead donor).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Category III includes patients whose condition has led to the decision of withdrawal or withholding of life-sustaining care. Following this decision, it is considered good clinical practice to consider the patient as a potential organ and tissue donor. The decision to withhold life-sustaining treatment should be made before, separately and completely independently from potential decisions regarding donation after death and the donation process. The transplant coordination team has to assess the appropriateness of the candidate and ensure that the time expected to elapse from withdrawal of life-sustaining treatment to death will be compatible with organ donation and not exceed the warm ischaemia time threshold established by the transplantation care team. The paediatric intensive care team is responsible for the patient and, completely removed from the donation process, for providing end-of-life care to ensure the well-being and comfort of the patient and for withdrawing life-sustaining therapies. This team is also responsible for death certification, which according to current law, requires verifying the absence of spontaneous circulation and breathing for a period of at least 5 minutes.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The outcomes of organ transplantation in this donation category, such as kidney and liver transplantation, have not been worse compared to the outcomes of transplants from heart-beating brain-dead donors.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Category III controlled DCD has been performed successfully in adult intensive care units and currently amounts to 30% of all donations.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3,4</span></a> Although this type of donation has grown significantly in recent years in countries like the United States and Canada,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4</span></a> it continues to be rare in Spain.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We present the case of a girl aged 15 months with noncompaction dilated cardiomyopathy and severe ventricular dysfunction who required support with an external ventricular assist device and was placed on the transplant waitlist. At 22 days from admission in the paediatric intensive care unit (PICU) she developed convulsive seizures, with imaging revealing the presence of a subdural haematoma with midline shift that required surgery. After 72 hours, there was evidence of an acute ischaemic stroke of the left middle cerebral artery that in 3 days had progressed to massive strokes with bilateral involvement of the anterior and middle cerebral arteries and the basal ganglia. Given the poor prognosis, the decision was made to withdraw life-sustaining treatment. The donation protocol was activated after this decision, and the patient was evaluated by the transplant coordination team, while the family expressed the wish to donate. The assessment by the transplant team found positive results for the kidney, liver (although a compatible recipient was not found for this organ) and tissues. The patient had not gone through brain death, so this was a controlled DCD donation. The process involved transport of the patient to an operating room (while the urology team got ready in an adjacent room), where mechanical ventilation and the ventricular assist device were withdrawn. During the entire process, the paediatric intensive care specialists in charge of the patient maintained sedation and analgesia per the life-sustaining therapy withdrawal protocol. Sixteen minutes after supportive care was withdrawn, the patient was declared death based on the absence of electrical and mechanical cardiac activity.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This has been the first case of controlled DCD carried out in our PICU, and we considered that sharing this information would be relevant, as many health care professionals are still unfamiliar with the process and few guidelines have been published on DCD in paediatric patients.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> To increase the possibility of transplantation in this age group, the Organización Nacional de Trasplantes (National Transplant Organization of Spain), in the framework of Plan 50<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>22 (to achieve 50 donors per million inhabitants in the 2018–2022 period), proposed establishing guidelines in collaboration with paediatrics and neonatology associations on paediatric donation in general and paediatric donation after circulatory death in particular.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, in the field of paediatrics, controlled organ donation after circulatory death should be considered in any patient in whom withdrawal of life-sustaining therapies is anticipated. This approach could increase the number of potential donors, but specific protocols need to be developed and its particularities in the paediatric population need to be investigated to extend this practice to paediatric patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Butragueño Laiseca L, Sancho González M, López-Herce Cid J, Mencía Bartolomé S. Donación en asistolia controlada en el paciente pediátrico. An Pediatr (Barc). 2020;92:299–300.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric donation after circulatory determination of death: a scoping review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.J. Weiss" 1 => "L. Hornby" 2 => "W. Witteman" 3 => "S.D. 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| 2022 August | 45 | 46 | 91 |
| 2022 July | 55 | 53 | 108 |
| 2022 June | 35 | 34 | 69 |
| 2022 May | 59 | 42 | 101 |
| 2022 April | 36 | 33 | 69 |
| 2022 March | 67 | 47 | 114 |
| 2022 February | 40 | 33 | 73 |
| 2022 January | 60 | 41 | 101 |
| 2021 December | 41 | 43 | 84 |
| 2021 November | 51 | 36 | 87 |
| 2021 October | 77 | 83 | 160 |
| 2021 September | 53 | 39 | 92 |
| 2021 August | 53 | 44 | 97 |
| 2021 July | 36 | 20 | 56 |
| 2021 June | 39 | 33 | 72 |
| 2021 May | 47 | 29 | 76 |
| 2021 April | 120 | 37 | 157 |
| 2021 March | 64 | 30 | 94 |
| 2021 February | 42 | 12 | 54 |
| 2021 January | 40 | 16 | 56 |
| 2020 December | 51 | 14 | 65 |
| 2020 November | 34 | 18 | 52 |
| 2020 October | 36 | 6 | 42 |
| 2020 September | 69 | 28 | 97 |
| 2020 August | 28 | 37 | 65 |
| 2020 July | 39 | 40 | 79 |
| 2020 June | 43 | 27 | 70 |
| 2020 May | 72 | 32 | 104 |
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