(1531) Donation After Circulatory Determination of Death on Pediatric ECMO: Single-Center Experience

Introduction: Pediatric solid organ transplantation is a resource-scarce situation with lengthening waitlist. The majority of pediatric transplant patients receive organs from deceased as opposed to living donors, classically from patients declared brain dead. Although donation after circulatory determination of death (DCDD) has helped to expand the donor organ pool for the adult population, it is less common in pediatrics due to concerns of prolonged warm ischemia time and delayed graft dysfunction in DCDD compared to donation after brain death. We describe our institutional experience of DCDD from donors who had been on Extracorporeal Membrane Oxygenation (ECMO), a novel approach in pediatric donation.

Description: Patient 1: 15 year-old female, BMI >35, systemic lupus erythematosus, type 2 diabetes mellitus and severe psychiatric comorbidities who ingested 24 grams of hydroxychloroquine. She had an out of hospital cardiac arrest due to refractory arrhythmia with subsequent ECMO-CPR on to VA-ECMO. CT scan brain revealed severe hypoxic-ischemic changes in conjunction with severe background suppression on continuous EEG. Given the child’s poor neurologic prognosis, the family opted to redirect care and pursue DCDD.
Patient 2: 16 year-old female, BMI >40 but otherwise healthy, who presented with severe ARDS due to COVID-19 pneumonia requiring VV-ECMO. Anticipating a long ECMO run given her extensive pulmonary parenchymal destruction, tracheostomy was done on ECMO day 11 while lung transplant evaluation was pursued. The patient was deemed not eligible for lung transplantation, and supported by her family, she voiced her desire to be an organ donor. She underwent DCDD, donating kidneys and liver.

Discussion: DCDD from ECMO involves a multidisciplinary team (pediatric ICU, operating room team, organ procurement organization representatives, ethics, and ECMO team) approach for coordinated and seamless clinical care. The DCDD procedure entailed withdrawal of ECMO support in the OR, followed by organ procurement after declaration of death. In the described context, ECMO provided hemodynamic stability with minimal warm ischemia time for the donated organs. This approach offers a novel resource for pediatric organ transplantation, potentially providing more donors in this resource-scarce setting.