Spontaneous ROSC After Withdrawal of Care in a Child
August 31, 2021
Written by Clay Smith
After withdrawal of life-sustaining treatment (WLST), the authors argue, based on this case and other case reports in children and adults, that a circulatory declaration of death be made after cessation of respiration and pulsatile arterial flow for 5 minutes, instead of just 2 minutes, prior to organ donation.
Why does this matter?
We have talked about the Lazarus phenomenon or autoresuscitation before – that patients can have ROSC up to a few minutes after cardiac arrest and termination of resuscitative efforts. Most organizations recommend waiting anywhere from 2 to 30 minutes post-arrest to determine death. In WLST, a circulatory determination of death is important when families choose organ donation. But how long should there be absence of respiration and arterial waveform before determining circulatory death has occurred?
Not a good surprise
This was a case report about a 2 year old child with influenza B who worsened in the hospital, developed bacterial tracheitis, and arrested after suctioning despite rapid CPR and intubation. They provided ICU care and TTM. On day 8, there was severe hypoxic ischemic injury on MRI and only posturing and slight cough to suctioning on exam. Family chose WLST and organ donation. The child was taken to the OR for extubation and was held by the family. See the graph.
There was complete cessation of breathing and arterial waveform for > 2 minutes. Then the child resumed spontaneous breathing and pulsatile arterial waveform and had a SBP up to 140 mmHg. Family was brought back in and held the child until the second cessation of respiration and pulse; kidneys were harvested after circulatory determination of death. Of note, the family was not upset, “framing it as having a ‘strong-willed child.’” The authors noted that the AAP recommends 2-5 minutes prior to making a circulatory determination of death and initiation of organ donation. The authors argued that 5 minutes is a better time target.
Unassisted Return of Spontaneous Circulation Following Withdrawal of Life-Sustaining Therapy During Donation After Circulatory Determination of Death in a Child. Crit Care Med. 2021 Aug 6. doi: 10.1097/CCM.0000000000005273. Online ahead of print.