title: Prediction of potential for organ donation after cardiac death in patients in neurocritical state: a prospective observational study.
abstract: BACKGROUND
  Successful donation of organs after cardiac death (DCD) requires identification of patients who will die within 60 min of withdrawal of life-sustaining treatment (WLST). We aimed to validate a straightforward model to predict the likelihood of death within 60 min of WLST in patients with irreversible brain injury.
  
  
  METHODS
  In this multicentre, observational study, we prospectively enrolled consecutive comatose patients with irreversible brain injury undergoing WLST at six medical centres in the USA and the Netherlands. We assessed four clinical characteristics (corneal reflex, cough reflex, best motor response, and oxygenation index) as predictor variables, which were selected on the basis of previous findings. We excluded patients who had brain death or were not intubated. The primary endpoint was death within 60 min of WLST. We used univariate and multivariable logistic regression analyses to assess associations with predictor variables. Points attributed to each variable were summed to create a predictive score for cardiac death in patients in neurocritical state (the DCD-N score). We assessed performance of the score using area under the curve analysis.
  
  
  RESULTS
  We included 178 patients, 82 (46%) of whom died within 60 min of WLST. Absent corneal reflexes (odds ratio [OR] 2·67, 95% CI 1·19-6·01; p=0·0173; 1 point), absent cough reflex (4·16, 1·79-9·70; p=0·0009; 2 points), extensor or absent motor responses (2·99, 1·22-7·34; p=0·0168; 1 point), and an oxygenation index score of more than 3·0 (2·31, 1·10-4·88; p=0·0276; 1 point) were predictive of death within 60 min of WLST. 59 of 82 patients who died within 60 min of WLST had DCD-N scores of 3 or more (72% sensitivity), and 75 of 96 of those who did not die within this interval had scores of 0-2 (78% specificity); taking into account the prevalence of death within 60 min in this population, a score of 3 or more was translated into a 74% chance of death within 60 min (positive predictive value) and a score of 0-2 translated into a 77% chance of survival beyond 60 min (negative predictive value).
  
  
  CONCLUSIONS
  The DCD-N score can be used to predict potential candidates for DCD in patients with non-survivable brain injury. However, this score needs to be tested specifically in a cohort of potential donors participating in DCD protocols.
  
  
  BACKGROUND
  None.
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, MN, USA. rabinstein.alejandro@mayo.edu
authors.forename: Alejandro A
authors.initials: AA
authors.lastname: Rabinstein
authors.forename: Alan H
authors.initials: AH
authors.lastname: Yee
authors.forename: Jay
authors.initials: J
authors.lastname: Mandrekar
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Fugate
authors.forename: Yorick J
authors.initials: YJ
authors.lastname: de Groot
authors.forename: Erwin J O
authors.initials: EJ
authors.lastname: Kompanje
authors.forename: Lori A
authors.initials: LA
authors.lastname: Shutter
authors.forename: W David
authors.initials: WD
authors.lastname: Freeman
authors.forename: Michael A
authors.initials: MA
authors.lastname: Rubin
authors.forename: Eelco F M
authors.initials: EF
authors.lastname: Wijdicks
mesh_terms: D001925:Brain Damage, Chronic / Q000401:mortality*; D003422:Critical Care / Q000706:statistics & numerical data*; D003625:Data Collection / Q000706:statistics & numerical data; D003643:Death; D006801:Humans; D011336:Probability; D011446:Prospective Studies; D012372:ROC Curve; D013996:Time and Motion Studies; D009927:Tissue and Organ Procurement / Q000706:statistics & numerical data*; D055986:Vital Signs; D028761:Withholding Treatment / Q000706:statistics & numerical data*