Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Pediatr. Feb 8, 2016; 5(1): 89-94
Published online Feb 8, 2016. doi: 10.5409/wjcp.v5.i1.89
Validation of a pediatric bedside tool to predict time to death after withdrawal of life support
Ashima Das, Ingrid M Anderson, David G Speicher, Richard H Speicher, Steven L Shein, Alexandre T Rotta
Ashima Das, Ingrid M Anderson, David G Speicher, Richard H Speicher, Steven L Shein, Alexandre T Rotta, Division of Pediatric Critical Care Medicine, Rainbow Babies and Children’s Hospital, Cleveland, OH 44106, United States
Ashima Das, Ingrid M Anderson, David G Speicher, Richard H Speicher, Steven L Shein, Alexandre T Rotta, Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
Author contributions: Das A, Anderson IM, Speicher DG, Speicher RH, Shein SL and Rotta AT contributed to study design and planning; Das A and Anderson IM contributed to data collection; Das A, Anderson IM and Rotta AT contributed to analysis data; Das A contributed to draft of the manuscript; Das A, Anderson IM, Speicher DG, Speicher RH, Shein SL and Rotta AT contributed to editing and finalization this manuscript.
Supported by Health Resources and Services Administration, NO. 234-2005-37011C.
Institutional review board statement: The study was reviewed and approved by the UH Rainbow Babies and Children’s Hospital Institutional Review Board.
Informed consent statement: This is a retrospective study restricted to data collection of deidentified information. Informed consent was not required by the IRB.
Conflict-of-interest statement: The authors do not report any conflict of interest related to this work.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Alexandre T Rotta, MD, Division of Pediatric Critical Care Medicine, Rainbow Babies and Children’s Hospital, 11100 Euclid Avenue, RBC 6010, Cleveland, OH 44106, United States. alex.rotta@uhhospitals.org
Telephone: +1-216-8443310
Received: August 17, 2015
Peer-review started: August 19, 2015
First decision: October 27, 2015
Revised: November 3, 2015
Accepted: December 3, 2015
Article in press: December 4, 2015
Published online: February 8, 2016
Processing time: 164 Days and 14.7 Hours
Abstract

AIM: To evaluate the accuracy of a tool developed to predict timing of death following withdrawal of life support in children.

METHODS: Pertinent variables for all pediatric deaths (age ≤ 21 years) from 1/2009 to 6/2014 in our pediatric intensive care unit (PICU) were extracted through a detailed review of the medical records. As originally described, a recently developed tool that predicts timing of death in children following withdrawal of life support (dallas predictor tool [DPT]) was used to calculate individual scores for each patient. Individual scores were calculated for prediction of death within 30 min (DPT30) and within 60 min (DPT60). For various resulting DPT30 and DPT60 scores, sensitivity, specificity and area under the receiver operating characteristic curve were calculated.

RESULTS: There were 8829 PICU admissions resulting in 132 (1.5%) deaths. Death followed withdrawal of life support in 70 patients (53%). After excluding subjects with insufficient data to calculate DPT scores, 62 subjects were analyzed. Average age of patients was 5.3 years (SD: 6.9), median time to death after withdrawal of life support was 25 min (range; 7 min to 16 h 54 min). Respiratory failure, shock and sepsis were the most common diagnoses. Thirty-seven patients (59.6%) died within 30 min of withdrawal of life support and 52 (83.8%) died within 60 min. DPT30 scores ranged from -17 to 16. A DPT30 score ≥ -3 was most predictive of death within that time period, with sensitivity = 0.76, specificity = 0.52, AUC = 0.69 and an overall classification accuracy = 66.1%. DPT60 scores ranged from -21 to 28. A DPT60 score ≥ -9 was most predictive of death within that time period, with sensitivity = 0.75, specificity = 0.80, AUC = 0.85 and an overall classification accuracy = 75.8%.

CONCLUSION: In this external cohort, the DPT is clinically relevant in predicting time from withdrawal of life support to death. In our patients, the DPT is more useful in predicting death within 60 min of withdrawal of life support than within 30 min. Furthermore, our analysis suggests optimal cut-off scores. Additional calibration and modifications of this important tool could help guide the intensive care team and families considering DCD.

Keywords: Death; Organ donation; Children; Donation after circulatory death

Core tip: Donation after circulatory death (DCD) has gained acceptance as a way of increasing the number of organs available for transplantation. In order for DCD to occur, organs must be harvested within 30 or 60 min of withdrawal of support. A tool that predicts time of death after withdrawal of support in children has been created but not validated by an external source. In this study, we apply the newly created Dallas Predictor Tool to an external pediatric sample and show it to be an accurate predictor of death within 60 min of withdrawal of support. The tool would require additional calibration to be a good predictor of death within 30 min.