Withdrawal Of Support Research Articles

P0455 / #1198: CARING FOR ACTIVELY DYING CHILDREN AND THEIR PARENTS IN THE PEDIATRIC ICU: A MIXED METHODS STUDY – PRELIMINARY QUANTITATIVE FINDINGS

Aims & Objectives: End-of-life (EOL) care is steeped in tradition, locally bound, and historically has not been informed by parent perspectives. This study uses a mixed methods design (QUAN → qual) to explain and contextualize quantitative clinical data with parent interviews about their child’s EOL care. Here, we present QUAN data describing a cohort of children with acute respiratory failure who died following withdrawal of support. Methods: Secondary analysis of the RESTORE dataset including demographics, baseline characteristics and care trajectories for up to 5 days prior to death. Results: Data reflect 67 patients from 24 U.S. PICUs. Nonsurvivors were primarily white (79%), non-Hispanic (78%) with PCPC/POPC ≤2 (69%). Diagnoses were acute (33%), complex-chronic disease (33%), or cancer (34%). Primary cause of death included respiratory (40%) or multisystem organ failure (27%). Prior to death, daily pain scores were 0 (modal), SBS were -1/-2 (modal). Opioid and benzodiazepine doses ranged from 6.0-4.4 mg/kg and 4.8-3.8 mg/kg, repectively. The nursing manpower use score (NEMS) increased from 33 to 36. On the day of death, 12% were supported on ECMO, 76% on vasopressors, 29% on dialysis and patients had a median of 5 medical devices in place. Eleven (16%) patients were extubated prior to death. Conclusions: Parents’grief following their critically ill child’s death is shaped by their memories around EOL care in the PICU. As patients approach EOL, nursing care requirements increased and many patients died with invasive devices/interventions, but with little to no pain. Qualitative and mixed-methods findings are forthcoming.

P0457 / #1797: COMPASSIONATE EXTUBATION IN PEDIATRIC INTENSIVE CARE UNIT: A SINGLE CENTER’S EXPERIENCE IN BRAZIL

Aims & Objectives: Compassionate extubation comprises the elective withdrawal of mechanical ventilation support and an approach to make the process as symptom-free and as well supported as possible for patients and their families. This study aimed to describe a series of cases of compassionate extubation in a pediatric intensive care unit (PICU) in Brazil. Methods: Retrospective case series. Results: Three patients underwent compassionate extubation. Age, primary diagnosis and underlying conditions at admission on PICU were: 7-month-old girl with anencephaly and pneumonia; 1-month-old girl with unfavorable complex heart disease; 7-year-old girl with untreatable metastatic neuroblastoma. After extubation, the patient with anencephaly was discharged, the oncologic patient was transferred to ward and died 2 days later, and the baby with heart disease died 1 hour later. Conclusions: Pediatric patients with life-limiting illness who are seriously ill may have different goals of care, including not prolonging the dying process and minimize suffering. In this setting, a role for pediatric palliative care specialist support and withdrawal of life-sustaining treatment is emerging. The process includes an interdisciplinary team approach, active symptoms management, setting expectations and postextubation plan of care. Ongoing survival following withdrawal of life-sustaining treatment is possible and difficult to predict.

Scaffold-Mediated Developmental Effects on Human Induced Pluripotent Stem Cell-Derived Cardiomyocytes Are Preserved After External Support Removal

Human induced pluripotent stem (hiPS) cells have been used as a cell source for regenerative therapy and disease modeling. The purity of hiPS-cardiomyocytes (hiPS-CMs) has markedly improved with advancements in cell culture and differentiation protocols. However, the morphological features and molecular properties of the relatively immature cells are still unclear, which has hampered their clinical application. The aim of the present study was to investigate the extent to which topographic substrates actively influence hiPS-CMs. hiPS-CMs were seeded on randomized oriented fiber substrate (random), anisotropic aligned fiber substrate (align), and flat non-scaffold substrate (flat). After culturing for one week, the hiPS-CMs on the aligned patterns showed more mature-like properties, including elongated rod shape, shorter duration of action potential, accelerated conduction velocity, and elevated cardiac gene expression. Subsequently, to determine whether this development was irreversible or was altered after withdrawal of the structural support, the hiPS-CMs were harvested from the three different patterns and reseeded on the non-scaffold (flat) pattern. After culturing for one more week, the improvements in morphological and functional properties diminished, although hiPS-CMs pre-cultured on the aligned pattern retained the molecular features of development, which were even more significant as compared to that observed during the pre-culture stage. Our results suggested that the anisotropic fiber substrate can induce the formation of geometrical mimic-oriented heart tissue in a short time. Although the morphological and electrophysiological properties of hiPS-CMs obtained via facilitated maturation somehow rely on the existence of an exterior scaffold, the molecular developmental features were preserved even in the absence of the external support, which might persist throughout hiPS-CM development.

Is donation after circulatory determination of death feasible for pediatric patients in italy?

To determine the potential effect of a donation after cardiac death active program on the number of organ donors in a Italian Pediatric Intensive Care Unit (PICU). We conducted a retrospective study of all deaths in PICU of an academic Children Hospital between 2012 and 2020, tracing the organ donation activity. Patients were categorized as brain deaths, deaths despite maximal resuscitation, and deaths after withdrawal or limitation of life support. Patient demographics, premortem physiology, end-of-life circumstances, and functional warm ischemia time were recorded. Eligible donors after cardiac death were identified by the absence of medical contraindication and functional warm ischemia time <60 minutes. Of 124 deaths that occurred during the study period, 34 met criteria for brain death, 23 were potential donors, and 13 became actual donors. Of the remaining 90 patients that met criteria for cardiac death, 66 died despite maximal resuscitation, 24 died after withdrawal or limitation of care and between them 13 were identified as theoretically eligible DCD donors. Of these, 5 patients had a functional warm ischemia time of <1 hour and were potential candidates for DCD of 10 kidneys and 2 lungs. Even if few children could have been eligible for DCD in the study period, an active program could have been able to increase the number of potential organ donors by 20% in the last eight years at our institution. DCD deserves to be explored in Italy as a new option for children.

Event-related potentials accompanying performance of computer mouse pointing task in the long-term dry immersion model of microgravity

Ten healthy volunteers participated in the ground imitation of a microgravity condition. For three weeks they stayed in the water filled tub without bodily support in supine position while isolated by waterproof material (this procedure is known as dry immersion - DI). During this period, they performed computer mouse pointing task and corresponding brain activity was evaluated by means of EEG: movement related and cognitive event-related potentials as well as resting state electroencephalogram were registered). Pointing task was performed before DI and at the time after initial period of adaptation – at the 5th and 17th days of DI. No deterioration of pointing task performance was found. Movement related potentials were not changed as well as cognitive peak P3, and only N1 peak significantly decreased at the 17th day of DI. Occipital alpha EEG also became significantly more pronounced at the 17th day of DI. Dry immersion procedure is thought to reproduce space flight physiological effects quite well, due to the DI specific feature – support withdrawal. Thus, results obtained indicate that support withdrawal also affects brain functioning in a specific way: increased alpha EEG is accompanied by altered visual processing (as indexed by diminished N1). Although these alterations are not sufficient to disrupt well learned mouse pointing task.

Evolving utilization of donation after circulatory death livers in liver transplantation: The day of DCD has come.

Compared to donation after brain death (DBD), livers procured for transplantation from donation after circulatory death (DCD) donors experience more ischemia-reperfusion injury and higher rates of ischemic cholangiopathy due to the period of warm ischemic time (WIT) following withdrawal of life support. As a result, utilization of DCD livers for liver transplant (LT) has generally been limited to short WITs and younger aged donor grafts, causing many recovered DCD organs to be discarded without consideration for transplant. This study assesses how DCD liver utilization and outcomes have changed over time, using OPTN data from adult, first-time, deceased donor, whole-organ LTs between January 1995 and December 2019. Results show that increased clinical experience with DCD LT has translated into increased use of livers from DCD donors, shorter ischemic times, shorter lengths of hospitalization after transplant, and lower rates of retransplantation. The data also reveal that over the past decade, the rate of increase in DCD LTs conducted in the United States has outpaced that of DBD. Together, these trends signal an opportunity for the field of liver transplantation to mitigate the organ shortage by capitalizing on DCD liver allografts that are currently not being utilized.

Out of the Ordinary: Confronting Paradox in the Historiography of Francoism

On 19 November 1975 Francisco Franco lay dying in Madrid's La Paz hospital. Clutching the cloak of the Virgin del Pilar, and with the ill-gotten relic of St Teresa of Ávila's hand at his bedside, the ailing dictator would soon depart this existence following the withdrawal of life support. For Enrique Moradiellos in Franco: Anatomy of a Dictator, the juxtaposition of modernity and tradition within this deathbed scene was emblematic of the countless paradoxes which characterised the Francoist dictatorship in its later years. Since the dictator's death scholars have continued to grapple with such paradoxes, struggling over how best to define a regime which has come to occupy a notoriously contentious space within contemporary Spanish politics and society. Like a fairground hall of mirrors, historical representations of Francoism have been stretched or squashed by different analytical frames, shaped in many cases by the political and social legacies of the dictatorship. Despite dubious claims to ‘objectivity’, the regime's apologists depict Francoism as a stabilising antidote to the ‘chaos’ of republicanism, conveniently overlooking the destruction and misery which followed the coup of 18 July 1936. Meanwhile, those who seek justice for the regime's victims continue to emphasise the repressive nature of the dictatorship. Though an important component of Francoism's modus operandi, repression does not, by itself, help us to fully understand Francoism's long-term survival or the consent it secured from millions of ordinary Spaniards. The titles under review reflect an increasing willingness to confront Francoism's many contradictions head-on, and to regard the paradoxical nature of the regime not as a conceptual knot to be disentangled, but as a historiographical problem in itself. Historians exploring the experiences of ‘ordinary’ people have proved particularly adept at addressing such complexities, as have scholars adopting comparative or transnational frameworks which reach beyond traditional emphasis on fascist Italy and Nazi Germany. The titles surveyed in this article offer a snapshot of recent developments in the field, while signposting potential avenues through which historians of Francoism might contribute to broader discussions within the historiography of modern Europe.

Conscientious Objection and Moral Reform in Medical Education

Whether the medical profession should accommodate conscientious objections (COs) remains an open question. I believe that doctors’ COs should be accommodated only when they are derived from their commitments about the nature of medicine (i.e., no doctor qua doctor should perform the objected-to service), and that the medical profession ought to accommodate these COs in order to maintain a system-level capacity for moral progress and self-correction [1]. The purpose of this project is to explore how, if at all, my conception of Nature of Medicine COs and their reform-based argument for accommodation apply to medical education. Specifically, I consider two questions: 1) Should medical students be able to enter specialties (i.e., apply to the residencies) that provide the objected-to services; and 2) should medical students’ COs be accommodated during their training? While some have answered the first question in the negative [2], I argue that medical students should be able to enter the specialties relevant to their Nature of Medicine COs. As potential members of the medical profession, medical students lack the rights and privileges of its present members, but they are nonetheless pivotal in determining its future moral trajectory. If anti-euthanasia students were kept out of the relevant specialties (viz., palliative care or critical care), those fields would eventually fill with pro-euthanasia doctors. Importantly, policymakers (i.e., legislators and doctors who represent the medical profession) should and do give greatest consideration to those most affected by their policies – for euthanasia, patients and active doctors in relevant specialties. Doctors who are regularly expected to perform abortions, for example, should and do have more of a voice in the abortion debate than cardiologists or retired doctors do. The medical profession would therefore become less likely to change its potentially wrong stance. Again, not just any CO will fit the bill here; they must be based on a reasonable conception of medicine and its moral obligations. Such refusals speak to what doctors qua doctors cannot do – in this case, perhaps the principle that no doctor should end or assist in ending a human life unless it would end on its own (as with withdrawal of life support) or save another life (as with emergency abortions). Assuming that principle is reasonable (in the sense that it may indeed be true), the CO is universalizable and therefore the right kind of thing to drive policy reform. The alternative would be COs that are based on personal idiosyncrasies, such as one’s religious beliefs, and would therefore not be universalizable. It would be inappropriate for such COs to drive policy reform, so my argument here would not protect them. It follows from my conclusion about the first question that medical students’ Nature of Medicine COs should be accommodated even before they become doctors. Otherwise, they might be so morally repulsed that they quit their medical education altogether. The specialties that provide the objected-to service would again fill with willing doctors, and the medical profession would find itself committed to potentially unethical policies. Importantly, this argument would fail if the empirical assumption that objecting students would quit were actually false. However, because of the United States’ long history of CO accommodations, we lack the data to verify that assumption. Ultimately, I wish to frame CO accommodations as a systemic feature of the medical profession that promotes moral self-correction, not a means of catering to the wishes of troublesome individuals. It follows from the need to maintain the profession’s ability to reform that medical students’ COs should be accommodated both during their training and when they decide which specialty to enter.

Temporal Evolution and Outcomes of Non-Traumatic Intracerebral Hemorrhage in Hospitalized Patients

ObjectiveTo investigate the radiographic features, temporal evolution, and outcome of patients who develop non-traumatic intracerebral hemorrhage (ICH) while hospitalized for other causes. MethodsWe retrospectively reviewed consecutive Emergency Department ICH (ED-ICH) and in-hospital ICH (IH-ICH) over an 8-year period. Variables including demographics, medical history, lab values, lead time to diagnosis, defined as time from last known well to first CT scan, and clinical characteristics, follow-up CT scan, as well as the frequency of withdrawal of life support were compared in the two groups. Mortality in correlation with ICH score was assessed. ResultsSixty-One IH-ICH and 216 ED-ICH patients were compared. History of cardiac disease, cancer, coagulopathy and higher SOFA score at time of diagnosis were significantly higher in the IH-ICH group (all P< 0.01). Time from symptom onset to diagnosis was shorter in the IH-ICH group (median 95 versus 117 minutes, P=0.011). Thirty six percent of IH-ICH fell into a worse ICH category when recalculated 6 hours from initial scan time, compared to only 10% of the ED-ICH. ICH score was well calibrated in ED-ICH when assessed both at diagnosis and 6 hours later, but underestimated actual mortality in the IH-ICH, particularly at ICH scores 0 to 3. End of life measures were pursued in 69% of IH-ICH group compared to 19% in the ED-ICH group. ConclusionsIH-ICH, is associated with higher overall mortality rates and often times heralds withdrawal of life sustaining therapies in patients. In addition, IH-ICH in comparison to ED-ICH, significantly changes in severity metrics within the first 6 hours. ICH score is not accurate and not calibrated to reflect reasonable stratification of mortality in IH-ICH. Prospective validation and investigation of variables accounting for higher IH-ICH mortality are needed.

Assessment of the Affordability of Out-of-Pocket Payments among Some Selected People Living with HIV in Kano, Nigeria

Introduction: With an estimated 1.8 million People Living with HIV (PLHIV), Nigeria’s HIV response is still heavily donor dependent. However, with anticipated decline in donor funding for HIV/AIDS program as the country takes ownership of the program, understanding financing options for PLHIV is important. One of such financing options is affordability of out-of-pocket payments (OOP) for anti-retroviral drugs (ARV) by PLHIV. We assessed affordability of OOP payments for ARVs in Kano State, North-Western Nigeria. Methods: Four Hundred and sixty-nine PLHIV receiving donor-supported-free ARV in Kano, North Western Nigeria were systematically selected and interviewed during routine clinic visits. Affordability for ARV was assessed by a combination of variables including willingness and financial means to incur extra expense for full dose of ARV based on landing and distribution cost of 8.3 USD (about 3,000 NGN) per month dose. Results: Four hundred and sixty-nine respondents were interviewed. Of those, 72 (15.4%, 95% CI: [13.2 - 19.7]) can afford ARV OOP on monthly base. The proportion of males able to pay 3,000 NGN (8.3 USD) or more OOP for ARVs was not different from that of women (15.5% versus 15.2%). Attending school, education level, employment, monthly income and wealth have all been found to be associated with willingness and ability to pay for monthly dose of ARV OOP (p < 0.0001). Conclusion/recommendation: Majority of PLHIV in Kano State may not afford ARV OOP in the event of withdrawal of supports by international donors. Innovative sustainable financing mechanisms from domestic resources are needed for HIV program sustainability.

M38 Duration of Extracorporeal Membrane Oxygenation Support Does Not Correlate With Survival

Extracorporeal membrane oxygenation (ECMO) offers patients in extremis an opportunity for recovery. The pulmonary/cardiopulmonary support provided by ECMO may obscure the patient’s underlying physiology making it difficult to differentiate between recovery and futility. Duration of ECMO support is often used by family and hospital staff to influence withdrawal of support. We examined the role that duration of ECMO support plays in predicting survival.

Moral distress in end-of-life decisions: A qualitative study of intensive care physicians.

The purpose is to explore triggers for moral distress, constraints preventing physicians from doing the right thing and ensuing consequences in making decisions for patients approaching end of life in intensive care. The qualitative study was undertaken in a tertiary referral intensive care unit in Northern Ireland in the United Kingdom. Drawing upon patient case studies of decisions about non escalation and/or withdrawal of life support, we undertook indepth interviews with senior and junior physicians. Interviews were transcribed verbatim and narratively analysed. Eighteen senior and junior physicians involved in 21 patient case studies were interviewed. Analysis determined two predominant themes: key moral distress triggers; and strategies and consequences. Junior residents reported most instances of moral distress, triggered by perceived futility, lack of continuity, protracted decisions and failure to ensure 'good death'. Senior physicians' triggers included constraint of clinical autonomy. Moral distress was far reaching, affecting personal life, working relationships and career choice. This study is the first to explore physicians' moral distress in end-of-life decisions in intensive care via a narrative inquiry approach using case studies. Results have implications for the education, recruitment and retention of physicians, relevant in the Covid 19 pandemic.

End-of-life practices in patients admitted to pediatric intensive care units in Brazil: A retrospective study

ObjectiveTo determine the prevalence of life support limitation (LSL) in patients who died after at least 24h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered. MethodsRetrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24h of admission. Results53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a do-not-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support. ConclusionsLSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support.

Anticipating the impacts of the COVID-19 pandemic on wildlife.

Author(s): Gaynor, Kaitlyn M; Brashares, Justin S; Gregory, Gillian H; Kurz, David J; Seto, Katherine L; Withey, Lauren S; Fiorella, Kathryn J

Abstract 338: Relationship Between Post-arrest Care Cardiac Index and Clinical Outcomes in Comatose Survivors of Out-of-hospital Cardiac Arrest: Insights From the CAPITAL-RETURN Trial

Introduction: Comatose survivors of out-of-hospital cardiac arrest (OHCA) have decreased cardiac index (CI) following return of spontaneous circulation. Although reversible, a reduced CI can contribute to cerebral hypoperfusion and impaired neurologic outcomes. We sought to examine the relationship between CI and clinical outcomes following OHCA. Methods: CAPITAL-RETURN was a prospective study examining hemodynamics in comatose survivors of OHCA undergoing targeted temperature management. Between August 2016 and December 2017, comatose survivors of OHCA with an initial shockable rhythm underwent continuous, blinded monitoring of CI using bioimpedance (Cheetah Medical, Portland, OR, USA) for 96 hours after intensive care unit (ICU) admission. In the present study, we examined the association between CI and the composite of death or severe neurologic dysfunction at 6 months (primary outcome) using logistic regression. Severe neurologic dysfunction was defined as a modified Rankin Scale score ≥4. We excluded patients who died or had withdrawal of advanced life support within 72 hours of ICU admission. Results: In 53 patients in this analysis (mean age 59±13 years, downtime 24±13 minutes, STEMI 35%), the rate of the primary outcome was 25%. The mean CI was lower in patients with (3.0±0.5 L/min/m 2 ) versus without (3.3±0.5 L/min/m 2 ) the primary outcome (p=0.018). A higher mean CI during the first 96 hours of ICU admission was associated with lower rates of the primary outcome (OR 0.85 per 0.1L/min/m 2 increase in CI; p=0.025). This association persisted after adjusting for age and downtime (OR 0.78 per 0.1L/min/m2 increase in CI; p=0.014). Cardiac index was similar in patients with versus without the primary outcome at the end of the 96-hour monitoring period (Figure). Conclusion: In comatose survivors of OHCA with an initial shockable rhythm, a higher CI during the first 96 hours of ICU admission is associated with lower rates of death or severe neurologic dysfunction.

Therapeutic Alliance Between Bereaved Parents and Physicians in the PICU.

Therapeutic alliance is the collaborative bond that develops between patients/families and healthcare providers. Our objective is to determine the extent of therapeutic alliance bereaved parents perceive to have occurred with their child's physicians during their child's PICU stay, and associated factors. Multicenter observational study. Eight children's hospitals affiliated with the Collaborative Pediatric Critical Care Research Network. Parents greater than or equal to 18 years old whose child died in a PICU (including cardiac ICU). Bereaved parents completed the Human Connection Scale, a 16-item measure of therapeutic alliance, 6 months after their child's death. Human Connection Scale scores range from 16 to 64 with higher scores indicating greater alliance. Parents provided sociodemographic data, and medical records were reviewed for the child's clinical characteristics. Two-hundred and thirty-three parents of 157 deceased children responded to the Human Connection Scale with greater than or equal to 80% item completion. Among parents, 146 (62.7%) were female, 155 (66.5%) were White and 46 (19.7%) were Black, 175 (75.1%) were married, and 209 (89.7%) had at least a high-school education. Among children, median age at the time of death was 5.9 years (interquartile range, 0.64-13.9 yr) and 114 (72.6%) died after limitation or withdrawal of life support. Mean Human Connection Scale score was 51.4 ± 11.1 for all parents, 52.6 ± 9.0 for White parents, and 47.0 ± 13.7 for Black parents. In multivariable modeling predicting Human Connection Scale scores, race was the only parent or child characteristic in the final model. Human Connection Scale scores were significantly different (-4.56; 95% CI, -8.53 to -0.6; p = 0.025) between the Black and White parents with items about trust, care, and honest communication showing the greatest mean difference. Among parents bereaved in the PICU, therapeutic alliance with physicians is moderately high. Future research should identify strategies to strengthen therapeutic alliance with Black parents and examine the role of alliance on bereaved parents' health outcomes.

The Role of Palliative Care in Withdrawal of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

ContextAs the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) increases, decisions regarding withdrawal from VA-ECMO increase. ObjectivesTo evaluate the clinical characteristics of patients withdrawn from VA-ECMO and the role of palliative care consultation in the decision. MethodsWe retrospectively reviewed adult patients with cardiogenic shock requiring VA-ECMO at our institution, who were withdrawn from VA-ECMO between January 1, 2014 and May 31, 2019. The relationship between clinical characteristics and palliative care visits was assessed, and documented reasons for withdrawal were identified. ResultsOf 460 patients who received VA-ECMO, 91 deceased patients (19.8%) were included. Forty-two patients (44.8%) had a palliative care consultation. The median duration on VA-ECMO was 4.0 days (interquartile range 8.8), and it was significantly longer for patients with palliative care consultation than those without (8.8 days vs. 2.0 days, P < 0.001). Among those with palliative care consultation, those with early consultation (within three days) had significantly shorter duration of VA-ECMO compared with those with late consultation (7.6 days vs. 13.5 days, t = 2.022, P = 0.008). Twenty-two (24.2%) had evidence of brain injury, which was significantly associated with patient age, number of comorbidities, duration of VA-ECMO, number of life-sustaining therapies, and number of palliative care visits (Wilks lambda 0.8925, DF 5,121, P = 0.016). Presence of brain injury was associated with fewer palliative care visits (t = 2.82, P = 0.006). ConclusionShorter duration of VA-ECMO support and presence of brain injury were associated with fewer palliative care visits. Decisions around withdrawal of VA-ECMO support might be less complicated when patient's medical conditions deteriorate quickly or when neurological prognosis seems poor.

Weaning strategies for the withdrawal of non-invasive respiratory support applying continuous positive airway pressure in preterm infants: a systematic review and meta-analysis

BackgroundThe optimal method to wean preterm infants from non-invasive respiratory support (NIVRS) with nasal continuous positive airway pressure (CPAP) or high-flow nasal cannula is still unclear, and methods used vary...

Do a surrogate decision-maker's motives matter?

Do a surrogate decision-maker's motives matter?

A Retrospective Review of Declined Lung Donors: Estimating the Potential of Ex Vivo Lung Perfusion

Even in the extended-criteria era, the reasons for declining lung donors are not always clear. Furthermore, it has not been determined how many actual declined lungs would be retrieved by exvivo lung perfusion (EVLP) beyond that already achieved in centers with an existing high utilization rate. This retrospective study reviewed all lung donor referrals between 2014 and 2018, including detailed formal referrals and preliminary notifications. This study categorized reasons for lung donor non-acceptance and estimated how many declined grafts could have been theoretically retrievable by using EVLP. In total, 966 lung donor candidates were referred, including 313 transplanted donors, 336 declined donors after detailed referrals (group A) and 258 preliminary declined. In group A, the primary reasons for refusal were lung quality issues (49%), general medical issues (25%), and organization issues (26%), combined with secondary reasons in many cases. Main lung quality issues were an extensive smoking history, abnormal chest radiography, and underlying lung disease. Although 73 declined lung donors had indications for EVLP, the retrievable lungs decreased to only 30 cases after considering the details of all clinical contraindications and organizational issues. Nevertheless, 59 intended donation after circulatory death donors did not progress to death after withdrawal of cardiorespiratory support in the required timeframe, and EVLP may have an emerging additional role here. Based on commonly cited criteria for EVLP indication, the number of EVLP retrievable lung donors represented only a small portion of declined donor lungs referred to our center from the state donation network.