Kramer Andreas H, Couillard Philippe L, Doig Christopher J, Kromm Julie A
Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.
Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada.
Neurocrit Care. 2025 Aug;43(1):204-211. doi: 10.1007/s12028-024-02204-x. Epub 2025 Jan 7.
Controlled donation after circulatory determination of death (DCD) is feasible only if circulatory arrest occurs soon after withdrawal of life-sustaining measures (WLSM). When organ recovery cannot proceed because this time interval is too long, there are potential negative implications, including perceptions of "secondary loss" for patients' families and significant resource consumption. The DCD-N score is a validated clinical tool for predicting rapid death following WLSM. We hypothesized that neuroimaging evidence of effaced perimesencephalic cisterns improves prediction of time to death compared with the DCD-N score alone.
In a retrospective population-based cohort study, DCD-N scores were prospectively determined in patients for whom consent for DCD had been obtained. Perimesencephalic cisterns on last available neuroimaging were assessed in duplicate and classified as normal, partially effaced, or completely effaced. Multivariable logistic regression assessed the capacity of DCD-N score and effaced cisterns to predict death within 1, 2, or 3 h of WLSM.
Of 164 consecutive patients, 49 (30%) progressed to death by neurologic criteria and were excluded. Of the remaining 115 patients, 81 (70%) died within 2 h of WLSM. When perimesencephalic cisterns were patent, this occurred in 48% of patients, compared with 88% and 93%, respectively, of patients with partially and completely effaced cisterns (p < 0.0001). In multivariable analysis, the odds ratio for prediction of death within 2 h was 7.2 (2.8-18.3) for each incremental DCD-N score and 15.4 (4.1-58.1) for the presence of either partially or completely effaced cisterns (c = 0.92 vs. 0.75-0.84 for univariate models). Results were comparable for prediction of death within 1 or 3 h. With patent cisterns, median time to death was 132.5 (21-420) minutes, compared with 23.5 (16-32) and 22 (19-30) minutes, respectively, with partially and completely effaced cisterns (p = 0.0002).
Cerebral edema with effaced perimesencephalic cisterns predicts rapid death following WLSM in potential DCD organ donors and improves on performance of the DCD-N score alone. Although originally validated for the prediction of death within 1 h, the DCD-N score remains predictive up to 3 h following WLSM.
只有在撤除维持生命措施（WLSM）后不久发生循环停止，循环判定死亡（DCD）后的可控捐赠才可行。当由于这个时间间隔过长而无法进行器官恢复时，会有潜在的负面影响，包括患者家属的“二次损失”感和大量资源消耗。DCD-N评分是一种经过验证的临床工具，用于预测WLSM后的快速死亡。我们假设，与单独使用DCD-N评分相比，中脑周围脑池消失的神经影像学证据可改善对死亡时间的预测。
在一项基于人群的回顾性队列研究中，对已获得DCD同意的患者前瞻性地确定DCD-N评分。对最后一次可获得的神经影像上的中脑周围脑池进行双份评估，并分类为正常、部分消失或完全消失。多变量逻辑回归评估DCD-N评分和脑池消失对预测WLSM后1、2或3小时内死亡的能力。
在164例连续患者中，49例（30%）根据神经学标准进展至死亡并被排除。在其余115例患者中，81例（70%）在WLSM后2小时内死亡。当中脑周围脑池通畅时，48%的患者出现这种情况，而部分和完全脑池消失的患者分别为88%和93%（p<0.0001）。在多变量分析中，对于预测2小时内死亡，DCD-N评分每增加一分的优势比为7.2（2.8 - 18.3），部分或完全脑池消失的优势比为15.4（4.1 - 58.1）（单变量模型中c = 0.92，与之相比为0.75 - 0.84）。对于预测1或3小时内死亡，结果具有可比性。当中脑周围脑池通畅时，中位死亡时间为132.5（21 - 420）分钟，而部分和完全脑池消失的患者分别为23.5（16 - 32）分钟和22（19 - 30）分钟（p = 0.0002）。
中脑周围脑池消失的脑水肿可预测潜在DCD器官捐赠者在WLSM后的快速死亡，并优于单独使用DCD-N评分。尽管DCD-N评分最初被验证用于预测1小时内的死亡，但在WLSM后长达3小时仍具有预测性。
