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February - 2021

   

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Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures

S Dhanani, L Hornby, A van Beinum et al for the Canadian Donation and Transplantation Research Program. NEJM, 2021, 384:345-352

Comment

Organ donation can only occur after death has occurred and been declared. Originally this was defined through brain death criteria. The introduction of donation after cardiac or circulatory death as a donation pathway, has allowed an increase in donation, and raised the complexity of balancing the timing of declaring death as irreversible cessation of circulation against the rapid progress of organ ischaemia. Practices vary internationally, with 2-10 minutes of apnea and pulselessness used as criteria for irreversible cessation of circulation. 

Concerns about autoresuscitation, or return of spontaneous circulation remain, and the longest reported period of pulselessness between terminated CPR and observed autoresuscitation is 10-minutes. Limited observational data suggests the time frame is shorter where life prolonging therapies are withdrawn. 

This prospective and retrospective observational study, the Death Prediction and Physiology after Removal of Therapy (DePPaRT) study, to describe the incidence and timing of resumption of cardiac electrical and pulsatile activity in critically ill adults who died after withdrawal of life-sustaining measures.

What did they do;

  • 20 adult ICUs in Canada, Czech Republic, Netherlands
  • Patients eligible if surrogate decision makers had agreed on care plan of withdrawal of life sustaining measures without CPR, and imminent death anticipated.  Patients fulfilling brain death criteria were excluded. 
  • Observations were recorded for at least 15-min prior and 30-mins after death determination. In the planned subgroup of organ donors, monitoring devices were removed 5-mins after pulselessness.
  • De-identified ECG and IABP data was uploaded to secure study site, and staff were asked to continue usual care. 
  • Clinicians reported resumption of circulation or cardiac activity prospectively (using ECG, IABP, palpable pulse, breath, physical movement), and independent retrospective reporting was performed analysing data (return of arterial pulse pressure of at least 5 mm Hg corresponding to at least one QRS complex, after a period of pulse pressure of less than 5 mm Hg for at least 60 seconds, as detected on IABP)

They report;

  • 631 patients enrolled, 32% eligible for organ donation through DCD, with 1/3 of these progressing to donation. 
  • Median time from start of withdrawal of life-sustaining measures to determination of death by cardiac criteria was 60 minutes (IQR, 21 to 283; range, 1 minute to 11 days 5 hours 54 minutes).
  • Prospective return of circulation occurred in 2% (13), confirmed retrospectively in 1% (5). Of the 5, ROSC occurred between 64 secs as 2 min 56 secs after period of pulselessness. 
  • Retrospective return of circulation was;
    • observed in 14% (67)
    • majority occurring between 1-2 minutes after pulselessness
    • longest duration 4 min 20 secs after
    • median duration of ROSC was 3.9 secs, ranging from 1 sec to 13 min 14 secs
    • 30-min waveform recordings post determination of death in 432 patients, all ROSC occurred within 5 minutes of pulselessness. 
    • Median time between last arterial pulse of at least 5mmHg and final QRS was 3 mins 37 secs (range 0 sec to 83 mins)

Overall, this study describes 1% of patients with loss of cardiac activity after planned withdrawal of life sustaining therapy have transient resumption of cardiac activity observable by bedside reports and corroborated by ECG and IABP waveform activity. Retrospective waveform review showed resumption of cardiac activity in 14% of patients. The longest period of pulselessness that was followed by resumption of cardiac activity was 4 minutes 20 seconds. No patients with resumption of cardiac activity regained consciousness or survived.

 

Abstract

BACKGROUND

The minimum duration of pulselessness required before organ donation after circulatory determination of death has not been well studied.

METHODS

We conducted a prospective observational study of the incidence and timing of resumption of cardiac electrical and pulsatile activity in adults who died after planned withdrawal of life-sustaining measures in 20 intensive care units in three countries. Patients were intended to be monitored for 30 minutes after determination of death. Clinicians at the bedside reported resumption of cardiac activity prospectively. Continuous blood-pressure and electrocardiographic (ECG) waveforms were recorded and reviewed retrospectively to confirm bedside observations and to determine whether there were additional instances of resumption of cardiac activity.

RESULTS

A total of 1999 patients were screened, and 631 were included in the study. Clinically reported resumption of cardiac activity, respiratory movement, or both that was confirmed by waveform analysis occurred in 5 patients (1%). Retrospective analysis of ECG and blood-pressure waveforms from 480 patients identified 67 instances (14%) with resumption of cardiac activity after a period of pulselessness, including the 5 reported by bedside clinicians. The longest duration after pulselessness before resumption of cardiac activity was 4 minutes 20 seconds. The last QRS complex coincided with the last arterial pulse in 19% of the patients.

CONCLUSIONS

After withdrawal of life-sustaining measures, transient resumption of at least one cycle of cardiac activity after pulselessness occurred in 14% of patients according to retrospective analysis of waveforms; only 1% of such resumptions were identified at the bedside. These events occurred within 4 minutes 20 seconds after a period of pulselessness.

February


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