Death by neurologic criteria and organ donation in German pediatric intensive care units – Data from the PIA network

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Despite identified barriers to pediatric organ donation, comprehensive data on characteristics and clinical management of pediatric deaths in German pediatric intensive care units (PICUs), especially those becoming organ donors remains limited. This study aims to analyze epidemiology of in-PICU deaths and characteristics of pediatric organ donors within a multicenter network of German PICUs. Methods Retrospective analysis of data prospectively collected in 33 PICUs participating in the Pediatric Intensive Care Unit Admission Network (PIA) between May 1, 2023 and July 31, 2025. Patients included were children older than 27 days and younger than 18 years who died during their PICU stay. Results Of 11,095 children recorded, 219 died (overall case-fatality rate: 1.97%). Median age at death was 6 years (IQR, 1– 13). Death occurred after withdrawal (30.1%) or limitation of life-sustaining treatment (20.5%), failed maximal therapy (26.5%) and failed cardiopulmonary resuscitation (12.8%). 21/219 (9.6%) children met neurologic criteria for death (brain death, BD). Of those, 11 families consented to organ donation (conversion rate: 52.4%). Median age of organ donors was 4 years (IQR 1–13). Conclusion This first national analysis shows comparable mortality rates but substantially lower brain death diagnosis rates in German PICUs than in international multicenter studies. This gap might suggest missed opportunities for organ donations. More structured donor identification, enhanced training for BD diagnosis, and development of evidence-based guidelines for pediatric donor management may enhance quality of care and increase pediatric organ donation in Germany. brain death1 children2 organ donation3 pediatric intensive care unit4 1 Introduction Advances in prenatal care, and neonatal, and pediatric intensive care medicine have significantly increased survival rates among newborns with congenital malformations and children with chronic or severe acute illnesses [1–5]. Subsequently, some of these conditions result in end-stage organ failure, necessitating organ transplantation. Over the past decade, 250 to 300 children have been listed for organ transplantation in Germany annually, while approximately 30 pediatric organ donations are realized each year [6]. Although adult organ transplantation in children is feasible, mismatches in size frequently limit this option to older children and adolescents or require organ splitting, which is not feasible for all organs. Furthermore, an older donor age may be associated with a decline in organ quality, particularly due to cardiovascular comorbidities [7, 8]. As donation rates fail to meet transplantation needs, waiting times for organ transplantation increase, resulting in substantial waiting list mortality. With an estimated mortality rate of 20% for patients not receiving a transplant within one year of being listed, pediatric heart transplant candidates face especially high risks, with infants being at even greater risk [9, 10]. Various barriers contribute to low organ donation rates in children. In addition to a lack of family consent - with lower consent rates for infants and toddlers [11, 12] - challenges in identifying and reporting potential donors to the relevant authorities are potential barriers to transplantation in both children and adults [13–15]. Furthermore, donation after cardiac death (DCD), accounting for 32% of total pediatric organ donations in the UK [16], is not permitted in Germany, where death by neurological criteria (donation after brain death, DBD) must first be diagnosed before organ transplantation can be considered [17]. In 2024, 2,188 infants, children and adolescents under the age of 18 died in Germany [18]. Nearly 200 deaths resulted from traumatic brain injury, drowning, or hypoxic events such as suffocation or foreign body aspiration [19]. This suggests potential for increased organ donation through thorough potential donor identification or diagnosis of irreversible loss of brain function. However, critical knowledge gaps impede efforts to improve pediatric organ donation in Germany, especially concerning factors distinguishing successful organ donors and other PICU deaths. A systematic analysis of differences in patient characteristics, clinical course, and intensive care interventions between these groups could identify modifiable factors and inform evidence-based strategies to optimize organ donation rates. Without this information, developing targeted interventions to increase donation rates remains challenging. In a unique attempt to establish a nationwide database in Germany on pediatric critical care, the Pediatric Intensive Care Unit Admissions (PIA) network was initiated in May 2023 [20]. Currently, 33 Pediatric Intensive Care Units (PICUs) actively participate in the data entry on admitted patients. In this study, we aimed to analyze 1) the epidemiology of in-PICU death within the PIA network, 2) characteristics of patients with organ donation after brain death, and 3) intensive care treatment in pediatric organ donors. 2 Methods Study Design and Population A retrospective analysis of data anonymously collected in 33 PICUs participating in the Pediatric Intensive Care Unit Admission (PIA) Network was conducted. Following the initiation of the network with three PICUs in May 2023, the network has grown gradually, with participating PICUs starting data entry at different time points. For this analysis, data from May 1, 2023 until July 31, 2025 were included. A detailed methodology report on the PIA network has been published previously [20]. Data are collected retrospectively and anonymously upon PICU discharge via electronic case report forms (eCRF) for eligible patients. A detailed survey is conducted on patients less than 18 years of age and older than 27 days and admitted to a PICU with a length of stay of at least 48 hours or in-hospital death within the first two days of their PICU admission. For this analysis we included all children who died during their PICU stay. Variables The detailed survey consists of six main sections: 1) Demographics (sex, age) and admission type (planned/unplanned, medical/surgical), 2) admission information, including pre-admission Pediatric Cerebral Performance Category Score (PCPC), 3) organ function within the first hour of admission 4) diagnosis and procedures, 5) interventions during PICU stay and 6) outcome at PICU discharge. Modes of death in the PICU are classified as follows: withdrawal or limitation of life-sustaining treatment (LST), failed maximal therapy, failed cardiopulmonary resuscitation (F-CPR), and brain death (BD). Statistical Analysis A descriptive analysis was performed with categorical variables presented as frequencies and percentages, continuous variables as mean and SD, or as median and interquartile range (IQR) whenever normal distribution was not achieved. SAS (version 9.4) was used for statistical analysis. 3 Results Epidemiology of death in the PIA network Over the 27-month study period, 11,095 children were admitted to participating PICUs, with 219 deaths recorded. Two children (0.9%) were declared dead on arrival, 217 (99.1%) died during their PICU stay. The overall case-fatality rate was 1.97%. The median age at death was 6 years (IQR, 1– 13 year). 44 (20.1%) patients were less than 1 year, 119 (54.3%) patients between 1 and 12 years, and 56 (25.6%) patients older than 12 years. Assessment of pre-admission neurological status using the PCPC revealed that 115 of 219 children who died (52.5%) had no prior neurological impairment 22 (10.1%) children had mild, 24 (11.0%) moderate and 41 (18.7%) severe neurological impairment before being admitted to the PICU. Details on the initial leading symptoms and underlying causes for PICU stay are shown in Table 1 . Death in the recorded 219 patients occurred after withdrawal of life-sustaining treatment (LST) in 66 (30.1%) and limitation of LST in 45 (20.5%) children, 58 (26.5%) died after failed maximal therapy, and 28 (12.8%) after failed cardiopulmonary resuscitation (F-CPR). In 1 (0.5%) patient, the circumstances of death are unknown. 21 (9.6%) met neurologic criteria for death. 3 Patients with neurologic criteria for death One patient (4.8%) met neurologic criteria for death upon arrival, 20 (95.2%) during their PICU stay. Of these, 11 families consented to donate organs with all patients donating organs (conversion rate of 52.4%, see Table 2 ). The median age of organ donors was 4 years (IQR 1–13 years). All organ donors had unplanned admissions, primarily for traumatic or surgical causes. Median length of stay on the PICU was three days (IQR 3–6,5 days), (see Table 2 ). Intensive care treatment in organ donors All patients who became organ donors received mechanical ventilation and cardiovascular support, predominantly for > 24hrs and ≤ 7days. The most frequently used vasotropic medications were Norepinephrine (100%), Milrinone (54.6%), Epinephrine (36.4%) and Dobutamine (45.5%). Hydrocortisone was administered to 2/11 (18.2%) patients. Extracorporeal treatment was used in 2 (18.2%) cases: one patient received plasmapheresis/immunoadsorption, and another VA-ECMO. No patient was treated with hemodialysis, hemofiltration, or peritoneal dialysis. Sedatives were used in 9 (81.8%), blood products in 10 (90.9%) patients (see Table 3 ). Table 1 Characteristics of discharged and deceased children with a detailed survey Discharged or transferred from PICU alive # (N = 3,790) Deceased (N = 219) Age [median (IQR)*] 4 (1–11) 6 (1–13) LOS § [median (IQR)] 6 (4–11) 4 (2–10) Neurological impairment pre-admission None Mild Moderate Severe Unknown 2198 (58.0%) 471 (12.4%) 376 (9.9%) 487 (12.9%) 258 (6.8%) 115 (52.5%) 22 (10.1%) 24 (11.0%) 41 (18.7%) 17 (7.7%) Leading symptom upon arrival [n (%)] Respiratory Cardiovascular Neurologic Nephrologic Gastrointestinal Dermatologic Musculoskeletal Hematopoietic/Lymphatic Other Unknown 1542 (40.7%) 324 (8.5%) 831 (21.9%) 134 (3.5%) 480 (12.7%) 25 (0.7%) 152 (4%) 118 (3.1%) 173 (4.6%) 11 (0.3%) 71 (32.4%) 52 (23.7%) 59 (26.9%) 1 (0.5%) 20 (9.1%) 0 (0%) 1 (0.5%) 1 (0.5%) 10 (4.6%) 4 (1.8%) Cause of leading symptom [n (%)] Infectious Immunological/Rheumatological Oncologic/Hematologic Transplant (solid organs) Transplant (bone marrow) Metabolic/Endocrine Trauma/Surgical Burns/Scalds/Chemical burns Respiratoric/Cardiocirculatoric and Neurologic Unknown 1548 (40.8%) 135 (3.6%) 391 (10.3%) 43 (1.1%) 40 (1.1%) 138 (3.6%) 668 (17.6%) 34 (0.9%) 707 (18.7%) 86 (2.3%) 66 (30.1%) 6 (2.7%) 17 (7.8%) 4 (1.8%) 10 (4.6%) 8 (3.7%) 27 (12.3%) 0 (0%) 50 (22.8%) 31 (14.2%) # Detailed survey in all children with a length of stay of at least 48 hours, 3,790/11,095;*IQR = interquartile range; § LOS = Length of stay. Table 2 Characteristics of children, who subsequently were declared brain dead Brain death WITHOUT organ donation (N = 10) Brain death WITH organ donation (N = 11) Age (median, IQR) 3.5 (1.25–8) 4 (1–13) LOS 4 (2–5.5) 3 (3–6.5) Neurological impairment pre-admission None Mild Moderate Severe Unknown 6 (60%) 2 (20%) 1 (10%) 1 (10%) 0 (0%) 8 (72.7%) 1 (9.1%) 1 (9.1%) 0 (0%) 1 (9.1%) Cause of leading symptom [n (%)] Infectious Immunologic/Rheumatologic Oncologic/Haematologic Transplant (solid organs) Transplant (bone marrow) Metabolic/Endocrine Trauma/Surgical Burns/Scalds/Chemical burns Respiratoric/Cardiocirculatoric and Neurologic Unknown 1 (10%) 0 (0%) 2 (20%) 0 (0%) 0 (0%) 0 (0%) 5 (50%) 0 (0%) 1 (10%) 1 (10%) 4 (36.4%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 5 (45.4%) 0 (0%) 2 (18.2%) 0 (0%) Table 3 Intensive care treatment in children, who were subsequently declared brain dead Brain death WITHOUT organ donation (N = 10) Brain death WITH organ donation (N = 11) Mechanical ventilation [n (%)] ≤ 24hrs > 24hrs and ≤ 7d > 7d and ≤ 28d 1 (10%) 7 (70%) 2 (20%) 1 (9.1%) 7 (63.61%) 3 (27.3%) Cardiocirculatory support [n (%)]* Norepinephrine Epinephrine Dobutamine Dopamine Vasopressin Milrinone Levosimendan Akrinor Hydrocortisone Others 8 (80%) 3 (30%) 3 (30%) 2 (20%) 0 (0%) 1 (10%) 0 (0%) 1 (10%) 4 (40%) 8 (80%) 11 (100%) 4 (36.4%) 5 (45.5%) 1 (9.1%) 1 (9.1%) 6 (54.6%) 1 (9.1%) 0 (0%) 2 (18.2%) 7 (63.6%) Duration of cardiocirculatory support ≤ 24hrs > 24hrs and ≤ 7d > 7d and ≤ 28d > 28d Unknown 0 (0%) 7 (70%) 3 (30%) 0 (0%) 1 (10%) 1 (9.1%) 8 (72.7%) 2 (18.2%) 0 (0%) 0 (0%) Extracorporeal treatment* Plasmapheresis/Immunoadsorption VA-ECMO Others 0 (0%) 0 (0%) 0 (0%) 1 (9.1%) 1 (9.1%) 2 (18.2%) Sedatives* Opioids Benzodiazepines Propofol Ketamin/Esketamin Volatile agents Alpha-agonists Others 6 (60%) 4 (40%) 1 (10%) 0 (0%) 0 (0%) 1 (10%) 6 (60%) 9 (81.8%) 4 (36.4%) 7 (63.6%) 1 (9.1%) 1 (9.1%) 1 (9.1%) 6 (54.6%) Duration of Sedation ≤ 24hrs > 24hrs and ≤ 7d > 7d and ≤ 28d Unknown 3 (30%) 4 (40%) 0 (0%) 3 (30%) 3 (27.3%) 3 (27.3%) 2 (18.2%) 3 (27.3%) Blood products* Erythrocyte concentrates Thrombocyte concentrate Fresh Frozen Plasma Coagulation factors Tranexamid Acid Albumin Fibrinogen IVIG Others 3 (30%) 1 (10%) 4 (40%) 2 (20%) 1 (10%) 2 (20%) 1 (10%) 2 (20%) 4 (40%) 6 (54.6%) 2 (18.2%) 4 (36.4%) 5 (45.5%) 0 (0%) 1 (9.1%) 3 (27.3%) 1 (9.1%) 6 (54.6%) *Multiple answers possible. 4 Discussion This study provides the first comprehensive analysis of death in pediatric patients in German PICUs and of patients who became pediatric organ donors through evaluation in the German Pediatric Intensive Care Unit Admission (PIA) Network. The retrospective analysis of 11,095 admissions across 33 PICUs identified 219 deaths, yielding a case fatality rate of 1.97% consistent with other high-income countries (1.8–2.7%) [21–24]. Our cohort’s median age at death (6 years, IQR 1–13) was higher than previous reports [24, 25], with only 20% of deaths in infancy and 25% in teens in our cohort. This age distribution may reflect differences in PICU admission or referral patterns in Germany. Neurological, respiratory, cardiovascular, and infectious conditions accounted for approximately half of deaths. This is a lower proportion than in other international cohorts [24], possibly due to an older age structure, lower pre-ICU arrest rates and a high proportion of deaths (14.2%) due to unknown reasons in our cohort. More than half of deceased children (52.5%) had no neurological impairments before being admitted to the PICU. However, we lack data on other non-neurological chronic conditions that often contributed to pediatric mortality in previous studies [21, 24, 26]. Among those with abnormal pre-admission PCPC scores, nearly half had severe neurological impairment. This may have influenced end-of-life decisions for some of these children. Decisions to limit life-sustaining treatment are particularly prevalent among children with severe neurological impairments and can significantly impact mortality rates [22, 24]. Half of deaths (50.6%) followed withdrawal or limitation of LST, aligning with reported European rates [22, 27] but slightly lower than those reported in non-European multicenter studies (63% − 70%) [24, 26, 28]. Unfortunately, we cannot fully characterize end-of-life practices, as information on DNR orders, the severity of illness prior to LST decisions, or rationale for LST was not available. Furthermore, our data cannot determine, how many children could have undergone brain death evaluation following the decision for LST. Only 21 of 219 deaths (9.6%) were attributed to brain death, markedly lower than the 15–23% reported in international multicenter studies [22, 28–31]. Several factors may explain this low rate: structural barriers (e.g. lack of standardized protocols for identifying potential brain death diagnosis), organizational limitations (e.g. insufficient resources for time- and labor-intensive protocolized BD evaluation) and limited clinical expertise in diagnosing pediatric BD [32, 33]. Among the 21 patients fulfilling the neurologic criteria of death, 11 (52.4%) donated organs, a conversion rate similar to other national multicenter studies in North America [30, 31] and higher than previously reported in German adult patients [34]. However, this rate is considerably lower than in other European countries, such as Spain [22]. Potential barriers for non-donation previously identified include late identification of potential donors, religious concerns, perceived medical contraindications or a reluctance to approach families of young children [12, 35], though age distribution was similar in our donor and non-donor group. Notably, five patients admitted for trauma did not donate organs which suggests barriers beyond medical suitability. Healthcare professionals' attitudes and experiences have been shown to have a significant impact on end-of-life care [36, 37] and can also influence organ donation consent rates for patients with neurological criteria for death [38]. The complexity of maintaining physiological stability in young potential donors—particularly those under two years—poses yet another challenge to successful organ donation [29], as reflected by the intensive use of vasoactive agents and blood products in BD patients who became donors in our cohort. Intensive care management of potential donors demands substantial resources, which may not be possible in some cases, potentially also impacting organ donation rates. Moreover, evidence based protocols on optimal intensive care management of potential pediatric organ donors remain limited. Most recommendations are based on established pediatric intensive care treatment principles or are derived from adult studies as ‘good clinical practice’ [39]. Finally, regional variability in PICU structures and processes likely contribute to differences in donation practices, further complicating standardization [40]. Strengths of this study include the large, geographically diverse national cohort and the systematic capture of PICU deaths within a network in which most pediatric deaths and all BD diagnoses occur. This provides a robust overview of circumstances surrounding pediatric death and organ donation in Germany. Limitations include potential reporting bias of participating PICUs in the PIA network, heterogeneous practices across PICUs, staggered network enrollment affecting temporal coverage, exclusion of the neonatal population, and the lack of granular data on LST decision-making and BD diagnosis processes. Conclusion This first national analysis reveals that German PICUs have comparable mortality rates but substantially lower brain death diagnosis rates than international centers. This gap might suggest missed opportunities for organ donations. The findings highlight the need for a systematic review of all PICU deaths for donation eligibility, protocols for identifying and evaluating of potential brain death cases, enhanced training for BD diagnosis, and development of evidence-based guidelines for pediatric donor management. There is an urgent need for national quality improvement initiatives targeting end-of-life care and organ donation processes. These interventions could improve pediatric organ donation rates, potentially saving lives of children awaiting organ transplantation. Declarations Ethics approval and consent to participate A formal ethic board review and approval was initially obtained from the Ethics Committee of the University Hospital of Mainz (study ID: 2022–16893). Local ethic board approvals were additionally obtained depending on the requirements of the local ethics committees of each participating hospital. The need for patients/legal guardian consent was waived by the approving ethics committee. Consent for publication All authors approved the final manuscript and consented for publication. Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding No funding was provided for this study. Author Contributions NM, CD, BD: Conceptualization, Methodology, Project administration, Writing – original draft, SB, MU: Methodology, Project administration, Software, Data curation, Writing – review and editing. FK, NB, CDS, FH, MO: Project administration, Writing – review and editing. All authors approved the final manuscript. Acknowledgments We thank the Pediatric section of the German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI) for their endorsement and ideational support of the PIA network. Availability of data and materials Not planned. Data Availability Statement The datasets [GENERATED/ANALYZED] for this study can be found in the [NAME OF REPOSITORY] [LINK]. Please see the “Availability of data” section of Materials and data policies in the Author guidelines for more details. References [1] Arantes RR, Aguiar MB, Cunha KCCMS, Amaral AA, Melo JRO, Vieira BCC, et al. 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Pediatr Crit Care Med. 2008;9:180-5. [39] Lücking K, , Seidemann K and Hoffmann F. Exkurs: Intensivtherapie des pädiatrischen Organspenders. Praxisleitfaden Organspende: Umsetzung der BÄK-Richtlinie „Spendererkennung“ in der Praxis. Berlin: Medizinisch Wissenschaftliche Verlagsgesellschaft; 2021. [40] Godown J, McKane M, Wujcik K, Mettler BA, Dodd DA. Expanding the donor pool: regional variation in pediatric organ donation rates. Pediatr Transplant. 2016;20:1093-7. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Mand","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYJACCYYKIMl88AGYDQRsEPED+LScAWK2ZAMStDC2wbUwENai23724O3CeXV1/G3MDMy8OyxAIs8e8+6pZeA73oBVi9mZvGTrmdsOS0gcA2k5IwEUSTc35nl2nEHyDHZrzA7kmEnzbjsgwXC//wAzb5tE/bYDaWzSPAeOMRjcSMCu5fwboJY5dRLyYFvagLacfwbVcv8Bdi03QLY0MEsYwLXcANtSA7QFu/fNbrwxtuY5dlhyI1DLwblgLc/YDeccOMAjeQaXw3IMb/PU1PHLHWNmfPC2rQ4oksb24M2BOjm+49i9jwKQlRzmIaweDdSRrGMUjIJRMAqGLQAAIjlabflm/NgAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-5973-3311","institution":"Marburg University, Faculty of Medicine, Neonatology and Pediatric Intensive Care, Department of Paediatrics, Marburg, Germany","correspondingAuthor":true,"prefix":"","firstName":"Nadine","middleName":"","lastName":"Mand","suffix":""},{"id":571378222,"identity":"dac90665-4e56-465e-8172-c966a926b208","order_by":1,"name":"Franziska König","email":"","orcid":"","institution":"Marburg University, Faculty of Medicine, Neonatology and Pediatric Intensive Care, Department of Paediatrics, Marburg, Germany","correspondingAuthor":false,"prefix":"","firstName":"Franziska","middleName":"","lastName":"König","suffix":""},{"id":571378324,"identity":"b71ced6e-4797-444a-87b9-cfab2f882c04","order_by":2,"name":"Sebastian Brenner","email":"","orcid":"https://orcid.org/0000-0002-3666-7128","institution":"Pediatric Intensive Care Medicine, Department of Pediatrics, University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Brenner","suffix":""},{"id":571378530,"identity":"2a90dc2e-ebfb-4119-8c81-70249cc15e9d","order_by":3,"name":"Nora Bruns","email":"","orcid":"https://orcid.org/0000-0003-3809-1887","institution":"Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany","correspondingAuthor":false,"prefix":"","firstName":"Nora","middleName":"","lastName":"Bruns","suffix":""},{"id":571378655,"identity":"d1753c54-e30f-4550-accf-a2221984fe07","order_by":4,"name":"Christian Dohna-Schwake","email":"","orcid":"https://orcid.org/0000-0001-8973-5406","institution":"Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Dohna-Schwake","suffix":""},{"id":571378726,"identity":"df6569f4-59cb-4c2c-a88a-05cb1a69fda5","order_by":5,"name":"Florian Hoffmann","email":"","orcid":"https://orcid.org/0000-0002-2713-2455","institution":"Department of Pediatrics, Klinikum Dritter Orden Munich, Munich, Germany","correspondingAuthor":false,"prefix":"","firstName":"Florian","middleName":"","lastName":"Hoffmann","suffix":""},{"id":571378803,"identity":"843b6460-3fe5-4eb4-8130-6b6e8befdd61","order_by":6,"name":"Martin Olivieri","email":"","orcid":"https://orcid.org/0000-0001-6434-6244","institution":"Pediatric Intensive Care Unit, Dr. von Hauner Children’s Hospital, LMU Munich, Munich, Germany","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Olivieri","suffix":""},{"id":571378855,"identity":"73e011cc-ccf3-46bc-801c-6b8fb12fd19a","order_by":7,"name":"Michael Urschitz","email":"","orcid":"","institution":"Division of Pediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Urschitz","suffix":""},{"id":571379100,"identity":"fe2721f1-0ea9-482e-9f2d-a229201034a6","order_by":8,"name":"Richard Biedermann","email":"","orcid":"https://orcid.org/0009-0002-0954-7267","institution":"Neonatal and Pediatric Intensive Care Section, Department of Child and Adolescent Medicine, University Hospital Jena, Jena, Germany","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Biedermann","suffix":""}],"badges":[],"createdAt":"2026-01-08 09:45:31","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8549742/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8549742/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100357747,"identity":"4621dec8-9ac5-46a3-8a02-aa4aa9684013","added_by":"auto","created_at":"2026-01-16 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06:40:01","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61162,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8549742/v1/9bf2780122ea68280bcde8bf.html"},{"id":100376936,"identity":"9522a117-ed06-4a6b-a682-7b8f8807b7d4","added_by":"auto","created_at":"2026-01-16 08:46:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":752655,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8549742/v1/7b69580a-1054-4195-8293-7824089030de.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eDeath by neurologic criteria and organ donation in German pediatric intensive care units – Data from the PIA network\u003c/p\u003e","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eAdvances in prenatal care, and neonatal, and pediatric intensive care medicine have significantly increased survival rates among newborns with congenital malformations and children with chronic or severe acute illnesses [1\u0026ndash;5]. Subsequently, some of these conditions result in end-stage organ failure, necessitating organ transplantation.\u003c/p\u003e \u003cp\u003eOver the past decade, 250 to 300 children have been listed for organ transplantation in Germany annually, while approximately 30 pediatric organ donations are realized each year [6]. Although adult organ transplantation in children is feasible, mismatches in size frequently limit this option to older children and adolescents or require organ splitting, which is not feasible for all organs. Furthermore, an older donor age may be associated with a decline in organ quality, particularly due to cardiovascular comorbidities [7, 8].\u003c/p\u003e \u003cp\u003eAs donation rates fail to meet transplantation needs, waiting times for organ transplantation increase, resulting in substantial waiting list mortality. With an estimated mortality rate of 20% for patients not receiving a transplant within one year of being listed, pediatric heart transplant candidates face especially high risks, with infants being at even greater risk [9, 10].\u003c/p\u003e \u003cp\u003eVarious barriers contribute to low organ donation rates in children. In addition to a lack of family consent - with lower consent rates for infants and toddlers [11, 12] - challenges in identifying and reporting potential donors to the relevant authorities are potential barriers to transplantation in both children and adults [13\u0026ndash;15]. Furthermore, donation after cardiac death (DCD), accounting for 32% of total pediatric organ donations in the UK [16], is not permitted in Germany, where death by neurological criteria (donation after brain death, DBD) must first be diagnosed before organ transplantation can be considered [17]. In 2024, 2,188 infants, children and adolescents under the age of 18 died in Germany [18]. Nearly 200 deaths resulted from traumatic brain injury, drowning, or hypoxic events such as suffocation or foreign body aspiration [19]. This suggests potential for increased organ donation through thorough potential donor identification or diagnosis of irreversible loss of brain function. However, critical knowledge gaps impede efforts to improve pediatric organ donation in Germany, especially concerning factors distinguishing successful organ donors and other PICU deaths. A systematic analysis of differences in patient characteristics, clinical course, and intensive care interventions between these groups could identify modifiable factors and inform evidence-based strategies to optimize organ donation rates. Without this information, developing targeted interventions to increase donation rates remains challenging.\u003c/p\u003e \u003cp\u003eIn a unique attempt to establish a nationwide database in Germany on pediatric critical care, the Pediatric Intensive Care Unit Admissions (PIA) network was initiated in May 2023 [20]. Currently, 33 Pediatric Intensive Care Units (PICUs) actively participate in the data entry on admitted patients. In this study, we aimed to analyze 1) the epidemiology of in-PICU death within the PIA network, 2) characteristics of patients with organ donation after brain death, and 3) intensive care treatment in pediatric organ donors.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003eStudy Design and Population\u003c/p\u003e \u003cp\u003eA retrospective analysis of data anonymously collected in 33 PICUs participating in the Pediatric Intensive Care Unit Admission (PIA) Network was conducted. Following the initiation of the network with three PICUs in May 2023, the network has grown gradually, with participating PICUs starting data entry at different time points. For this analysis, data from May 1, 2023 until July 31, 2025 were included.\u003c/p\u003e \u003cp\u003eA detailed methodology report on the PIA network has been published previously [20]. Data are collected retrospectively and anonymously upon PICU discharge via electronic case report forms (eCRF) for eligible patients. A detailed survey is conducted on patients less than 18 years of age and older than 27 days and admitted to a PICU with a length of stay of at least 48 hours or in-hospital death within the first two days of their PICU admission. For this analysis we included all children who died during their PICU stay.\u003c/p\u003e \u003cp\u003eVariables\u003c/p\u003e \u003cp\u003eThe detailed survey consists of six main sections: 1) Demographics (sex, age) and admission type (planned/unplanned, medical/surgical), 2) admission information, including pre-admission Pediatric Cerebral Performance Category Score (PCPC), 3) organ function within the first hour of admission 4) diagnosis and procedures, 5) interventions during PICU stay and 6) outcome at PICU discharge.\u003c/p\u003e \u003cp\u003eModes of death in the PICU are classified as follows: withdrawal or limitation of life-sustaining treatment (LST), failed maximal therapy, failed cardiopulmonary resuscitation (F-CPR), and brain death (BD).\u003c/p\u003e \u003cp\u003eStatistical Analysis\u003c/p\u003e \u003cp\u003eA descriptive analysis was performed with categorical variables presented as frequencies and percentages, continuous variables as mean and SD, or as median and interquartile range (IQR) whenever normal distribution was not achieved. SAS (version 9.4) was used for statistical analysis.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003eEpidemiology of death in the PIA network\u003c/p\u003e\n\u003cp\u003eOver the 27-month study period, 11,095 children were admitted to participating PICUs, with 219 deaths recorded. Two children (0.9%) were declared dead on arrival, 217 (99.1%) died during their PICU stay. The overall case-fatality rate was 1.97%.\u003c/p\u003e\n\u003cp\u003eThe median age at death was 6 years (IQR, 1\u0026ndash; 13\u0026nbsp;year). 44 (20.1%) patients were less than 1 year, 119 (54.3%) patients between 1 and 12 years, and 56 (25.6%) patients older than 12 years.\u003c/p\u003e\n\u003cp\u003eAssessment of pre-admission neurological status using the PCPC revealed that 115 of 219 children who died (52.5%) had no prior neurological impairment 22 (10.1%) children had mild, 24 (11.0%) moderate and 41 (18.7%) severe neurological impairment before being admitted to the PICU.\u003c/p\u003e\n\u003cp\u003eDetails on the initial leading symptoms and underlying causes for PICU stay are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eDeath in the recorded 219 patients occurred after withdrawal of life-sustaining treatment (LST) in 66 (30.1%) and limitation of LST in 45 (20.5%) children, 58 (26.5%) died after failed maximal therapy, and 28 (12.8%) after failed cardiopulmonary resuscitation (F-CPR). In 1 (0.5%) patient, the circumstances of death are unknown. 21 (9.6%) met neurologic criteria for death.\u003c/p\u003e\n\u003ch3\u003e3 Patients with neurologic criteria for death\u003c/h3\u003e\n\u003cp\u003eOne patient (4.8%) met neurologic criteria for death upon arrival, 20 (95.2%) during their PICU stay. Of these, 11 families consented to donate organs with all patients donating organs (conversion rate of 52.4%, see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe median age of organ donors was 4 years (IQR 1\u0026ndash;13 years). All organ donors had unplanned admissions, primarily for traumatic or surgical causes. Median length of stay on the PICU was three days (IQR 3\u0026ndash;6,5 days), (see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIntensive care treatment in organ donors\u003c/p\u003e\n\u003cp\u003eAll patients who became organ donors received mechanical ventilation and cardiovascular support, predominantly for \u0026gt;\u0026thinsp;24hrs and \u0026le;\u0026thinsp;7days. The most frequently used vasotropic medications were Norepinephrine (100%), Milrinone (54.6%), Epinephrine (36.4%) and Dobutamine (45.5%). Hydrocortisone was administered to 2/11 (18.2%) patients. Extracorporeal treatment was used in 2 (18.2%) cases: one patient received plasmapheresis/immunoadsorption, and another VA-ECMO. No patient was treated with hemodialysis, hemofiltration, or peritoneal dialysis. Sedatives were used in 9 (81.8%), blood products in 10 (90.9%) patients (see Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of discharged and deceased children with a detailed survey\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDischarged or transferred\u003c/p\u003e\n \u003cp\u003efrom PICU alive\u003csup\u003e#\u003c/sup\u003e (N\u0026thinsp;=\u0026thinsp;3,790)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDeceased\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;219)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge [median (IQR)*]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1\u0026ndash;11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (1\u0026ndash;13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLOS\u003csup\u003e\u0026sect;\u003c/sup\u003e [median (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (4\u0026ndash;11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeurological impairment pre-admission\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2198 (58.0%)\u003c/p\u003e\n \u003cp\u003e471 (12.4%)\u003c/p\u003e\n \u003cp\u003e376 (9.9%)\u003c/p\u003e\n \u003cp\u003e487 (12.9%)\u003c/p\u003e\n \u003cp\u003e258 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e115 (52.5%)\u003c/p\u003e\n \u003cp\u003e22 (10.1%)\u003c/p\u003e\n \u003cp\u003e24 (11.0%)\u003c/p\u003e\n \u003cp\u003e41 (18.7%)\u003c/p\u003e\n \u003cp\u003e17 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeading symptom upon arrival [n (%)]\u003c/p\u003e\n \u003cp\u003eRespiratory\u003c/p\u003e\n \u003cp\u003eCardiovascular\u003c/p\u003e\n \u003cp\u003eNeurologic\u003c/p\u003e\n \u003cp\u003eNephrologic\u003c/p\u003e\n \u003cp\u003eGastrointestinal\u003c/p\u003e\n \u003cp\u003eDermatologic\u003c/p\u003e\n \u003cp\u003eMusculoskeletal\u003c/p\u003e\n \u003cp\u003eHematopoietic/Lymphatic\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1542 (40.7%)\u003c/p\u003e\n \u003cp\u003e324 (8.5%)\u003c/p\u003e\n \u003cp\u003e831 (21.9%)\u003c/p\u003e\n \u003cp\u003e134 (3.5%)\u003c/p\u003e\n \u003cp\u003e480 (12.7%)\u003c/p\u003e\n \u003cp\u003e25 (0.7%)\u003c/p\u003e\n \u003cp\u003e152 (4%)\u003c/p\u003e\n \u003cp\u003e118 (3.1%)\u003c/p\u003e\n \u003cp\u003e173 (4.6%)\u003c/p\u003e\n \u003cp\u003e11 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e71 (32.4%)\u003c/p\u003e\n \u003cp\u003e52 (23.7%)\u003c/p\u003e\n \u003cp\u003e59 (26.9%)\u003c/p\u003e\n \u003cp\u003e1 (0.5%)\u003c/p\u003e\n \u003cp\u003e20 (9.1%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e1 (0.5%)\u003c/p\u003e\n \u003cp\u003e1 (0.5%)\u003c/p\u003e\n \u003cp\u003e10 (4.6%)\u003c/p\u003e\n \u003cp\u003e4 (1.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCause of leading symptom [n (%)]\u003c/p\u003e\n \u003cp\u003eInfectious\u003c/p\u003e\n \u003cp\u003eImmunological/Rheumatological\u003c/p\u003e\n \u003cp\u003eOncologic/Hematologic\u003c/p\u003e\n \u003cp\u003eTransplant (solid organs)\u003c/p\u003e\n \u003cp\u003eTransplant (bone marrow)\u003c/p\u003e\n \u003cp\u003eMetabolic/Endocrine\u003c/p\u003e\n \u003cp\u003eTrauma/Surgical\u003c/p\u003e\n \u003cp\u003eBurns/Scalds/Chemical burns\u003c/p\u003e\n \u003cp\u003eRespiratoric/Cardiocirculatoric and Neurologic\u003c/p\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1548 (40.8%)\u003c/p\u003e\n \u003cp\u003e135 (3.6%)\u003c/p\u003e\n \u003cp\u003e391 (10.3%)\u003c/p\u003e\n \u003cp\u003e43 (1.1%)\u003c/p\u003e\n \u003cp\u003e40 (1.1%)\u003c/p\u003e\n \u003cp\u003e138 (3.6%)\u003c/p\u003e\n \u003cp\u003e668 (17.6%)\u003c/p\u003e\n \u003cp\u003e34 (0.9%)\u003c/p\u003e\n \u003cp\u003e707 (18.7%)\u003c/p\u003e\n \u003cp\u003e86 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e66 (30.1%)\u003c/p\u003e\n \u003cp\u003e6 (2.7%)\u003c/p\u003e\n \u003cp\u003e17 (7.8%)\u003c/p\u003e\n \u003cp\u003e4 (1.8%)\u003c/p\u003e\n \u003cp\u003e10 (4.6%)\u003c/p\u003e\n \u003cp\u003e8 (3.7%)\u003c/p\u003e\n \u003cp\u003e27 (12.3%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e50 (22.8%)\u003c/p\u003e\n \u003cp\u003e31 (14.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003csup\u003e\u0026nbsp;\u003cem\u003e#\u003c/em\u003e\u0026nbsp;\u003c/sup\u003e \u003cem\u003eDetailed survey in all children with a length of stay of at least 48 hours, 3,790/11,095;*IQR\u0026thinsp;=\u0026thinsp;interquartile range;\u003c/em\u003e \u003csup\u003e\u003cem\u003e\u0026sect;\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eLOS\u0026thinsp;=\u0026thinsp;Length of stay.\u003c/em\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of children, who subsequently were declared brain dead\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBrain death WITHOUT organ donation (N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBrain death WITH organ donation\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (median, IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.5 (1.25\u0026ndash;8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1\u0026ndash;13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (2\u0026ndash;5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3\u0026ndash;6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeurological impairment pre-admission\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (60%)\u003c/p\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (72.7%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCause of leading symptom [n (%)]\u003c/p\u003e\n \u003cp\u003eInfectious\u003c/p\u003e\n \u003cp\u003eImmunologic/Rheumatologic\u003c/p\u003e\n \u003cp\u003eOncologic/Haematologic\u003c/p\u003e\n \u003cp\u003eTransplant (solid organs)\u003c/p\u003e\n \u003cp\u003eTransplant (bone marrow)\u003c/p\u003e\n \u003cp\u003eMetabolic/Endocrine\u003c/p\u003e\n \u003cp\u003eTrauma/Surgical\u003c/p\u003e\n \u003cp\u003eBurns/Scalds/Chemical burns\u003c/p\u003e\n \u003cp\u003eRespiratoric/Cardiocirculatoric and Neurologic\u003c/p\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e5 (50%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (36.4%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e5 (45.4%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIntensive care treatment in children, who were subsequently declared brain dead\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBrain death WITHOUT organ donation (N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBrain death WITH organ donation\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMechanical ventilation [n (%)]\u003c/p\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;24hrs\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;24hrs and \u0026le;\u0026thinsp;7d\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;7d and \u0026le;\u0026thinsp;28d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e7 (70%)\u003c/p\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e7 (63.61%)\u003c/p\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiocirculatory support [n (%)]*\u003c/p\u003e\n \u003cp\u003eNorepinephrine\u003c/p\u003e\n \u003cp\u003eEpinephrine\u003c/p\u003e\n \u003cp\u003eDobutamine\u003c/p\u003e\n \u003cp\u003eDopamine\u003c/p\u003e\n \u003cp\u003eVasopressin\u003c/p\u003e\n \u003cp\u003eMilrinone\u003c/p\u003e\n \u003cp\u003eLevosimendan\u003c/p\u003e\n \u003cp\u003eAkrinor\u003c/p\u003e\n \u003cp\u003eHydrocortisone\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (80%)\u003c/p\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003cp\u003e8 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (100%)\u003c/p\u003e\n \u003cp\u003e4 (36.4%)\u003c/p\u003e\n \u003cp\u003e5 (45.5%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e6 (54.6%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003cp\u003e7 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDuration of cardiocirculatory support\u003c/p\u003e\n \u003cp\u003e\u0026thinsp;\u0026le;\u0026thinsp;24hrs\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;24hrs and \u0026le;\u0026thinsp;7d\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;7d and \u0026le;\u0026thinsp;28d\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;28d\u003c/p\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e7 (70%)\u003c/p\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e8 (72.7%)\u003c/p\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExtracorporeal treatment*\u003c/p\u003e\n \u003cp\u003ePlasmapheresis/Immunoadsorption\u003c/p\u003e\n \u003cp\u003eVA-ECMO\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSedatives*\u003c/p\u003e\n \u003cp\u003eOpioids\u003c/p\u003e\n \u003cp\u003eBenzodiazepines\u003c/p\u003e\n \u003cp\u003ePropofol\u003c/p\u003e\n \u003cp\u003eKetamin/Esketamin\u003c/p\u003e\n \u003cp\u003eVolatile agents\u003c/p\u003e\n \u003cp\u003eAlpha-agonists\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (60%)\u003c/p\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e6 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (81.8%)\u003c/p\u003e\n \u003cp\u003e4 (36.4%)\u003c/p\u003e\n \u003cp\u003e7 (63.6%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e6 (54.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDuration of Sedation\u003c/p\u003e\n \u003cp\u003e\u0026thinsp;\u0026le;\u0026thinsp;24hrs\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;24hrs and \u0026le;\u0026thinsp;7d\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;7d and \u0026le;\u0026thinsp;28d\u003c/p\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlood products*\u003c/p\u003e\n \u003cp\u003eErythrocyte concentrates\u003c/p\u003e\n \u003cp\u003eThrombocyte concentrate\u003c/p\u003e\n \u003cp\u003eFresh Frozen Plasma\u003c/p\u003e\n \u003cp\u003eCoagulation factors\u003c/p\u003e\n \u003cp\u003eTranexamid Acid\u003c/p\u003e\n \u003cp\u003eAlbumin\u003c/p\u003e\n \u003cp\u003eFibrinogen\u003c/p\u003e\n \u003cp\u003eIVIG\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (54.6%)\u003c/p\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003cp\u003e4 (36.4%)\u003c/p\u003e\n \u003cp\u003e5 (45.5%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e6 (54.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003e*Multiple answers possible.\u003c/em\u003e\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study provides the first comprehensive analysis of death in pediatric patients in German PICUs and of patients who became pediatric organ donors through evaluation in the German Pediatric Intensive Care Unit Admission (PIA) Network. The retrospective analysis of 11,095 admissions across 33 PICUs identified 219 deaths, yielding a case fatality rate of 1.97% consistent with other high-income countries (1.8\u0026ndash;2.7%) [21\u0026ndash;24].\u003c/p\u003e \u003cp\u003eOur cohort\u0026rsquo;s median age at death (6 years, IQR 1\u0026ndash;13) was higher than previous reports [24, 25], with only 20% of deaths in infancy and 25% in teens in our cohort. This age distribution may reflect differences in PICU admission or referral patterns in Germany. Neurological, respiratory, cardiovascular, and infectious conditions accounted for approximately half of deaths. This is a lower proportion than in other international cohorts [24], possibly due to an older age structure, lower pre-ICU arrest rates and a high proportion of deaths (14.2%) due to unknown reasons in our cohort.\u003c/p\u003e \u003cp\u003eMore than half of deceased children (52.5%) had no neurological impairments before being admitted to the PICU. However, we lack data on other non-neurological chronic conditions that often contributed to pediatric mortality in previous studies [21, 24, 26]. Among those with abnormal pre-admission PCPC scores, nearly half had severe neurological impairment. This may have influenced end-of-life decisions for some of these children. Decisions to limit life-sustaining treatment are particularly prevalent among children with severe neurological impairments and can significantly impact mortality rates [22, 24].\u003c/p\u003e \u003cp\u003eHalf of deaths (50.6%) followed withdrawal or limitation of LST, aligning with reported European rates [22, 27] but slightly lower than those reported in non-European multicenter studies (63% \u0026minus;\u0026thinsp;70%) [24, 26, 28]. Unfortunately, we cannot fully characterize end-of-life practices, as information on DNR orders, the severity of illness prior to LST decisions, or rationale for LST was not available. Furthermore, our data cannot determine, how many children could have undergone brain death evaluation following the decision for LST. Only 21 of 219 deaths (9.6%) were attributed to brain death, markedly lower than the 15\u0026ndash;23% reported in international multicenter studies [22, 28\u0026ndash;31]. Several factors may explain this low rate: structural barriers (e.g. lack of standardized protocols for identifying potential brain death diagnosis), organizational limitations (e.g. insufficient resources for time- and labor-intensive protocolized BD evaluation) and limited clinical expertise in diagnosing pediatric BD [32, 33].\u003c/p\u003e \u003cp\u003eAmong the 21 patients fulfilling the neurologic criteria of death, 11 (52.4%) donated organs, a conversion rate similar to other national multicenter studies in North America [30, 31] and higher than previously reported in German adult patients [34]. However, this rate is considerably lower than in other European countries, such as Spain [22]. Potential barriers for non-donation previously identified include late identification of potential donors, religious concerns, perceived medical contraindications or a reluctance to approach families of young children [12, 35], though age distribution was similar in our donor and non-donor group. Notably, five patients admitted for trauma did not donate organs which suggests barriers beyond medical suitability. Healthcare professionals' attitudes and experiences have been shown to have a significant impact on end-of-life care [36, 37] and can also influence organ donation consent rates for patients with neurological criteria for death [38].\u003c/p\u003e \u003cp\u003eThe complexity of maintaining physiological stability in young potential donors\u0026mdash;particularly those under two years\u0026mdash;poses yet another challenge to successful organ donation [29], as reflected by the intensive use of vasoactive agents and blood products in BD patients who became donors in our cohort. Intensive care management of potential donors demands substantial resources, which may not be possible in some cases, potentially also impacting organ donation rates. Moreover, evidence based protocols on optimal intensive care management of potential pediatric organ donors remain limited. Most recommendations are based on established pediatric intensive care treatment principles or are derived from adult studies as \u0026lsquo;good clinical practice\u0026rsquo; [39]. Finally, regional variability in PICU structures and processes likely contribute to differences in donation practices, further complicating standardization [40].\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths\u003c/b\u003e of this study include the large, geographically diverse national cohort and the systematic capture of PICU deaths within a network in which most pediatric deaths and all BD diagnoses occur. This provides a robust overview of circumstances surrounding pediatric death and organ donation in Germany. \u003cb\u003eLimitations\u003c/b\u003e include potential reporting bias of participating PICUs in the PIA network, heterogeneous practices across PICUs, staggered network enrollment affecting temporal coverage, exclusion of the neonatal population, and the lack of granular data on LST decision-making and BD diagnosis processes.\u003c/p\u003e \u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e This first national analysis reveals that German PICUs have comparable mortality rates but substantially lower brain death diagnosis rates than international centers. This gap might suggest missed opportunities for organ donations. The findings highlight the need for a systematic review of all PICU deaths for donation eligibility, protocols for identifying and evaluating of potential brain death cases, enhanced training for BD diagnosis, and development of evidence-based guidelines for pediatric donor management. There is an urgent need for national quality improvement initiatives targeting end-of-life care and organ donation processes. These interventions could improve pediatric organ donation rates, potentially saving lives of children awaiting organ transplantation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e A formal ethic board review and approval was initially obtained from the Ethics Committee of the University Hospital of Mainz (study ID: 2022\u0026ndash;16893). Local ethic board approvals were additionally obtained depending on the requirements of the local ethics committees of each participating hospital. The need for patients/legal guardian consent was waived by the approving ethics committee.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e All authors approved the final manuscript and consented for publication.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of Interest\u003c/h2\u003e \u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was provided for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contributions\u003c/h2\u003e \u003cp\u003eNM, CD, BD: Conceptualization, Methodology, Project administration, Writing \u0026ndash; original draft, SB, MU: Methodology, Project administration, Software, Data curation, Writing \u0026ndash; review and editing. FK, NB, CDS, FH, MO: Project administration, Writing \u0026ndash; review and editing. All authors approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003e We thank the Pediatric section of the German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI) for their endorsement and ideational support of the PIA network.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eNot planned.\u003c/p\u003e\u003ch2\u003eData Availability Statement\u003c/h2\u003e \u003cp\u003eThe datasets [GENERATED/ANALYZED] for this study can be found in the [NAME OF REPOSITORY] [LINK]. Please see the \u0026ldquo;Availability of data\u0026rdquo; section of Materials and data policies in the Author guidelines for more details.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e[1] Arantes RR, Aguiar MB, Cunha KCCMS, Amaral AA, Melo JRO, Vieira BCC, et al. 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Acta Paediatr. 2019;108:1460-6.\u003c/p\u003e\n\u003cp\u003e[24] Moynihan KM, Alexander PMA, Schlapbach LJ, Millar J, Jacobe S, Ravindranathan H, et al. Epidemiology of childhood death in Australian and New Zealand intensive care units. Intensive Care Medicine. 2019;45:1262-71.\u003c/p\u003e\n\u003cp\u003e[25] Hanneg\u0026aring;rd Hamrin T, Eksborg S. Risks for death after admission to pediatric intensive care (PICU)-A comparison with the general population. PLoS One. 2022;17:e0265792.\u003c/p\u003e\n\u003cp\u003e[26] Meert KL, Keele L, Morrison W, Berg RA, Dalton H, Newth CJ, et al. End-of-Life Practices Among Tertiary Care PICUs in the United States: A Multicenter Study. Pediatr Crit Care Med. 2015;16:e231-8.\u003c/p\u003e\n\u003cp\u003e[27] Devictor DJ, Latour JM. Forgoing life support: how the decision is made in European pediatric intensive care units. Intensive Care Med. 2011;37:1881-7.\u003c/p\u003e\n\u003cp\u003e[28] Burns JP, Sellers DE, Meyer EC, Lewis-Newby M, Truog RD. 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Jama. 2020;324:1078-97.\u003c/p\u003e\n\u003cp\u003e[33] Toulouse J, Hully M, Brossier D, Viallard ML, de Saint Blanquat L, Renolleau S, et al. The role of the neuropediatrician in pediatric intensive care unit: Diagnosis, therapeutics and major participation in collaborative multidisciplinary deliberations about life-sustaining treatments' withdrawal. Eur J Paediatr Neurol. 2019;23:171-80.\u003c/p\u003e\n\u003cp\u003e[34] Englbrecht JS, Schrader D, Kraus H, Sch\u0026auml;fer M, Schedler D, Bach F, et al. How Large is the Potential of Brain Dead Donors and what Prevents Utilization? A Multicenter Retrospective Analysis at Seven University Hospitals in North Rhine-Westphalia. Transpl Int. 2023;36:11186.\u003c/p\u003e\n\u003cp\u003e[35] de Freitas RA, Dell'Agnolo CM, Alves EF, Benguella EA, Pelloso SM, Carvalho MD. Organ and tissue donation for transplantation from fatal trauma victims. Transplant Proc. 2015;47:874-8.\u003c/p\u003e\n\u003cp\u003e[36] Zanin A, Brierley J, Latour JM, Gawronski O. End-of-life decisions and practices as viewed by health professionals in pediatric critical care: A European survey study. Front Pediatr. 2022;10:1067860.\u003c/p\u003e\n\u003cp\u003e[37] Williams MA, Lipsett PA, Rushton CH, Grochowski EC, Berkowitz ID, Mann SL, et al. The physician's role in discussing organ donation with families. Crit Care Med. 2003;31:1568-73.\u003c/p\u003e\n\u003cp\u003e[38] Rodrigue JR, Cornell DL, Howard RJ. Pediatric organ donation: what factors most influence parents' donation decisions? Pediatr Crit Care Med. 2008;9:180-5.\u003c/p\u003e\n\u003cp\u003e[39] L\u0026uuml;cking K, , Seidemann K and Hoffmann F. Exkurs: Intensivtherapie des p\u0026auml;diatrischen Organspenders. Praxisleitfaden Organspende: Umsetzung der B\u0026Auml;K-Richtlinie \u0026bdquo;Spendererkennung\u0026ldquo; in der Praxis. Berlin: Medizinisch Wissenschaftliche Verlagsgesellschaft; 2021.\u003c/p\u003e\n\u003cp\u003e[40] Godown J, McKane M, Wujcik K, Mettler BA, Dodd DA. Expanding the donor pool: regional variation in pediatric organ donation rates. Pediatr Transplant. 2016;20:1093-7.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"brain death1, children2, organ donation3, pediatric intensive care unit4","lastPublishedDoi":"10.21203/rs.3.rs-8549742/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8549742/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction\u003c/b\u003e\u003c/p\u003e \u003cp\u003eEach year, between 250 and 300 children are listed for organ transplantation in Germany, while approximately 30 children donate organs. Despite identified barriers to pediatric organ donation, comprehensive data on characteristics and clinical management of pediatric deaths in German pediatric intensive care units (PICUs), especially those becoming organ donors remains limited. This study aims to analyze epidemiology of in-PICU deaths and characteristics of pediatric organ donors within a multicenter network of German PICUs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e Retrospective analysis of data prospectively collected in 33 PICUs participating in the Pediatric Intensive Care Unit Admission Network (PIA) between May 1, 2023 and July 31, 2025. Patients included were children older than 27 days and younger than 18 years who died during their PICU stay.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOf 11,095 children recorded, 219 died (overall case-fatality rate: 1.97%). Median age at death was 6 years (IQR, 1\u0026ndash; 13). Death occurred after withdrawal (30.1%) or limitation of life-sustaining treatment (20.5%), failed maximal therapy (26.5%) and failed cardiopulmonary resuscitation (12.8%). 21/219 (9.6%) children met neurologic criteria for death (brain death, BD). Of those, 11 families consented to organ donation (conversion rate: 52.4%). Median age of organ donors was 4 years (IQR 1\u0026ndash;13).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis first national analysis shows comparable mortality rates but substantially lower brain death diagnosis rates in German PICUs than in international multicenter studies. This gap might suggest missed opportunities for organ donations. More structured donor identification, enhanced training for BD diagnosis, and development of evidence-based guidelines for pediatric donor management may enhance quality of care and increase pediatric organ donation in Germany.\u003c/p\u003e","manuscriptTitle":"Death by neurologic criteria and organ donation in German pediatric intensive care units – Data from the PIA network","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-09 06:39:56","doi":"10.21203/rs.3.rs-8549742/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"96c35239-10d1-44d5-b035-18b22d683e4e","owner":[],"postedDate":"January 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-09T06:39:56+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-09 06:39:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8549742","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8549742","identity":"rs-8549742","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}