prediction of death in adults– an educated guess in dcds maria c. nauman rrt, cptc resource triage...
TRANSCRIPT
Prediction of death in adults–an educated guess in DCDs
Maria C. Nauman RRT, CPTCResource Triage Coordinator
California Transplant Donor Network
Objective
• Why we needed to change our practice• Describe how we changed our practice• Review our process for DCDs• Review some of the challenges of the tool• 2014 Data
Why change our method?
• Not reaching our goal of 10% DCD cases• More Objective• Article on predicting death–Dr Alan Yee, Neurologist, CPMC–Probability Tool
• 2012 initiated changes to our practice
Factors influencing time to death after withdrawal of life support in neurocritical patientsA.H. Yee, A.A. Rabinstein, P. Thama, et al. Neurology 2010; 74; 1380
• Retrospective study (2002-2008) Neuro ICU• 149 pts• Compared those who died <60 and >60• Excluding those who were declared BD, not
intubated, or had insufficient data• Correlation associated with earlier death after
withdrawal of life sustaining measures– Absent corneals, cough, extension, O2 index <4.2
Probability Tool
1. Enter FiO2, MAP, and PaO2 to generate oxygenation index.
FiO2 Mean Airway Pressure PaO2 Oxygenation Index
Oxygenation index:
http://www-users.med.cornell.edu/~spon/picu/calc/oxyindex.htm
2. Enter Y or N as appropriate to generate probability.
Corneal reflex? Cough reflex? Motor response 3-6?
Oxygenation index >4.2? Probability
Y = Yes 1 - No motor response
N = No 2 - Decerebrate posturing/extension
3 - Decorticate posturing/flexion
4 - Withdrawal
5 - Localizes
6 - Obeys commands
Monthly Review
Decision
Huddle
Evaluation Tool
Review
Referral
History
Diagnostics
SBTs
Clinical picture
Labs
Vent
Respiratory status
2014 Data
Score Cases Accuracy
<70 37 89%
70-80 14 57%
>80 18 87.5%
Problems
• How to score when the reflex is intermittent• How to score when we have to assess by phone• Assessments such as NIF and leak test – Equipment not available for NIF– Technique dependent
• Not having updated clinical information– ABGs, diagnostics
• It’s still an educated guess!
Questions?