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Practice Variation in Intraoperative Management of Pediatric Organ Donation After Brain Death: A Retrospective
Phil Y Yao1,2, Abhijit V Lele2, Michael J Souter2
1Department of Pediatric Anesthesiology, Seattle Children's Hospital, Seattle, Washington, USA.
Insights
Pediatric organ donation faces a shortage, with significant variations in how brain-dead donors are managed during organ recovery. Improving consistency in perioperative care for these donors is crucial.
Area of Science:
- Pediatric critical care medicine
- Organ transplantation
- Neurosurgery
Background:
- Critical shortage of pediatric organ donors.
- Limited understanding of optimal perioperative management for pediatric brain-dead donors.
- Need to optimize donor organ outcomes for pediatric recipients.
Purpose of the Study:
- To survey practice patterns in intraoperative management of pediatric (age < 18 years) brain-dead donors.
- Evaluate variations in organ recovery procedures.
- Identify differences in management based on center volume.
Main Methods:
- Retrospective observational study of 231 organ recovery cases (2014-2020).
- Data from 24 centers in the Multicenter Perioperative Outcomes Group (MPOG) cohort.
- Analysis of practice variation using descriptive statistics, Fleiss' kappa, and logistic regression, comparing higher-volume (≥10 cases) and lower-volume (<10 cases) centers.
Main Results:
- Substantial differences observed in case volume, race, and administration of steroids and vasoactive medications.
- Negative Fleiss' kappa scores indicated a lack of within-group agreement on medication administration.
- Lower-volume centers showed significantly lower odds of steroid administration (OR=0.319, p=0.014).
Conclusions:
- Significant practice variation exists in the perioperative management of pediatric brain-dead donors across MPOG centers.
- Lack of consistency in management strategies, from case classification to medication use.
- Opportunity to improve perioperative care by aligning practices with brain death physiology to optimize organ outcomes.
Background:
There remains a critical shortage of pediatric organ donors and there is a gap in understanding of optimal perioperative management to optimize donor organ outcomes for this valuable resource.
Aims:
To survey practice patterns for intraoperative management of pediatric (age < 18 years) brain-dead donors during organ recovery procedures.
Methods:
This retrospective observational study included organ recovery cases from 24 centers included in the Multicenter Perioperative Outcomes Group (MPOG) cohort in the United States from 2014 to 2020. Practice variation was evaluated using descriptive statistics, Fleiss' kappa, and logistic regression for between-group comparisons for volume-based analysis (case volume < 10 or ≥ 10) without adjustment for multiple comparisons.
Results:
A total of 231 cases were included in this analysis. The median case volume for the Higher-Volume (≥ 10 cases) group was 25 [IQR 17, 46] cases and 7 [IQR 3, 8] cases for the Lower-Volume (< 10 cases) group. Descriptive analyses identified differences in case volume, race, and administration of steroids and vasoactives (bolus and infusion). The Fleiss' kappa scores were negative across all medications administered, suggesting a lack of within-group agreement. The odds ratio for steroid administration in the Lower-Volume group was 0.319 (95% CI: 0.116-0.745, p = 0.014).
Conclusions:
This study found substantial practice variation across MPOG centers grouped based on case volume frequency for organ recovery procedures in pediatric donation after brain death. A major limitation of this study is the inability to correlate perioperative management with organ recipient outcomes. The main takeaway is an opportunity to improve consistency in perioperative management for brain-death donors from case classification to medication administration that reflects an understanding of brain death physiology.
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