February - 2021
Showing Journal 3 of 5
Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures
NEJM, 2021, 384:345-352
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 Limited observational data suggests the time frame is shorter where life prolonging therapies are withdrawn.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;
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.
The minimum duration of pulselessness required before organ donation after circulatory determination of death has not been well studied.
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.
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.
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.
No Comments yet.