Could identifying cardiac arrest patients with no chance of survival help reduce organ shortage?

By Will Boggs MD

NEW YORK (Reuters Health) - Three objective criteria can identify patients with out-of-hospital cardiac arrest (OHCA) who have no chance of survival but might still provide organs for donation, according to a retrospective study.

The three criteria are: OHCA not witnessed by emergency medical service (EMS), non-shockable initial cardiac rhythm, and no return of spontaneous circulation with 3 mg of epinephrine.

When these criteria are met, "the resuscitation process is inefficient," Dr. Xavier Jouven from Hopital Europeen Georges Pompidou in Paris told Reuters Health by email. "Spending less time on resuscitation for patients with 0% of survival criteria (helps save) the lives of organ waitlisted patients."

Despite improvements in resuscitation techniques, mortality rates after OHCA are as high as 94%. Clinical decision "termination-of-resuscitation" rules aim to avoid ambulance transport where resuscitation is futile but do not take into consideration the potential utility of transporting dead patients to the hospital for organ donation.

Dr. Jouven's team used data from two published registries and one published clinical trial managed by 2 EMS systems in France and the United States to evaluate objective and practical criteria for identifying patients with OHCA and no chance of survival during the first minutes of advanced CPR.

The three criteria above, tested in 1771 patients, predicted 0% survival with a positive predictive value (PPV) and specificity of 100%.

In a validation cohort of 3656 patients, when the three objective criteria were met, only one patient survived to hospital discharge in a persistent vegetative state, according to the September 13th Annals of Internal Medicine report.

Among 486 patients from France and 2669 patients from the U.S. with OHCA of presumed cardiac origin, no patient who met the three objective criteria survived to hospital discharge.

As many as 12% of patients with no chance of survival who were screened for organ donation eligibility according to the French clinical criteria might have had organs suitable for transplantation.

"The shortage of organs is an important and growing issue with thousands of patients dying in the waiting list," Dr. Jouven said. "Symmetrically, the number of potential kidneys for potential organ donation is huge considering the high incidence of cardiac arrest (around 300,000 per year in United States). Our results represent a big hope in terms of public health."

"Certain medical doctors, public, and health care communities will have difficulties accepting this new approach, but the debate is worth it because on the other side patients with end-stage chronic diseases and waitlisted for organ donation are suffering," he said. "The final aim of the study is to be more efficient with organ donation when there is absolutely no hope of survival after cardiac arrest."

"Resuscitation must always focus first on the patient's survival," the researchers emphasize. "Uncontrolled donation after cardiac death (UDCD) can be considered only after achievement of this primary goal is no longer feasible. Our results will enable futile prolonged resuscitation on site to be limited when patients with OHCA could be directed to an organ donation center."

"I hope these results will contribute to help emergency medicine and resuscitation international and national societies to elaborate new recommendations about out-of-hospital cardiac patients," Dr. Jouven concluded.

Dr. Kevin G. Munjal, an emergency medicine physician at Mount Sinai Medical Center in New York City told Reuters Health, "The study briefly references but does not fully address the profound ethical questions that have thus far prevented the proliferation of UDCD in the United States. That is that our current construct requires that preservation activities not be initiated until after death is determined. And that determination of death should not be made until all available resources have been exhausted."

"Thus, even if these criteria are valid for termination of resuscitation, and thus in predicting death, we could not apply these criteria to identify potential organ donors unless our society revisits our current ethical constructs around determination of death and the dead donor rule," Dr. Munjal concluded.

SOURCE: https://bit.ly/2cjy6Kb

Ann Intern Med 2016.