1. Regional Collaborative November 2015. NDT Case study Paediatric - H Bethan Thomas Specialist Nurse – Organ Donation

2. Regional Collaborative November 2015. Background 10 yr old Cerebral Palsy Global developmental delay Microcephaly Epilepsy Scoliosis Quadriplegia PEG fed- no swallow Previous abdominal compartment syndrome with bowel ischaemia leading to bowel resection Worsening T2RF (normal pCO2 10-14 reported by paediatrician) Recurrent LRTI Home O2 Recent discharge from hospital after admission for chest infection

3. Regional Collaborative November 2015. Day 4 BSDT Preconditions CVS stable on noradrenaline and dopamine –BP map 66 pCO2 8.95 pO2 49.5 pH 7.41 GCS 3 - unsedated Temp 39ºC (>24 hours) Lab results: Na 153 K+ 3.2 PO4 1.12 Mg 0.69

4. Regional Collaborative November 2015. Day 4 Pupils 2mm-fixed BSDT started- breathed during apnoea test Test done by 2 PICU consultants 2 nd set not done. Test 1 Time Pre Apnoea Test 14:13 Post Apnoea Test 14:20 pH7.4127.243 pO249.58.52 pCO28.9513.6 HCO3-41.942.4 ABE15.413.1

5. Regional Collaborative November 2015. Day 5 BSDT Preconditions CVS stable on noradrenaline and dopamine –BP map 80 pH 7.33 pCO2 8.52 pO2 19.3 GCS 3 - unsedated Temp 38.7ºC (>24 hours) Lab results: Na 173 K+ 3.1 PO4 1.36 Mg 0.79

6. Regional Collaborative November 2015. Day 5 Repeat BSDT ‘Gasped’ at the end of the second set of tests. Test 1 Time Pre Apnoea Test 13:14 Post Apnoea Test 13:22 Test 2 Time Pre Apnoea Test 19:09 Post Apnoea Test 19:28 pH7.3887.189pH7.3327.123 pO258.157.5pO219.318.7 pCO27.6513.0pCO28.5214.4 HCO3-33.835.8HCO3-32.933.8 ABE8.15.8ABE6.53.1

7. Regional Collaborative November 2015. Parents given the option of withdrawing treatment after these tests

8. Regional Collaborative November 2015. Day 6 BSDT Preconditions CVS stable on noradrenaline and dopamine –BP map 65 pH 7.36 pCO2 7.04 pO2 23.2 GCS 3 - unsedated Temp 36.8ºC (>24 hours) Lab results: Na 160 K+ 3.7 PO4 0.8 Mg 0.94

9. Regional Collaborative November 2015. Day 6 Third set of BSDT were performed H breathed on the first set but after a prolonged time off the ventilator (around 7 minutes) Test 1 Time Pre Apnoea Test 15:46 Post Apnoea Test 16:07 pH7.3577.193 pO223.218.2 pCO27.0410.8 HCO3-28.930 ABE3.51.1

10. Regional Collaborative November 2015. Outcome Parents at this time were told that neurological death was now very unlikely to occur due to the amount of time past since her hypoxic event. H’s parents remained positive about organ donation and proceeded as a DCD saving 4 lives.

11. Regional Collaborative November 2015. Discussion points No CT scan was done. Known aetiology was history and clinical presentation. EEG day 2- very low amplitude with no convincing cerebral activity H was a known CO 2 retainer with normal CO 2 sitting around 10-12 kPa and prior to admission 12-14 kPa H’s usual oxygen levels on facemask of 1l SaO2 >95% and on 2l via nasal cannulae >90%