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

Introduction Each 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. 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.