Download - Management of the Potential Organ Donor
Management of the Potential Organ Donor
Kenneth E. Wood, D.O.
Professor of Medicine and Anesthesiology
Senior Director of Medical Affairs
Director of Critical Care Medicine and Respiratory Care
The Trauma and Life Support Center
University of Wisconsin Hospital and Clinics
DisclaimerNo Financial Support
Slides Available by [email protected]
Maximal Utilization and Optimal Management of Potential Organ Donors
• Surveillance to identify patients with severe neurologic injury likely to progress to brain death
• Standardized method for brain death declaration
• Uniform request for consent
• Optimal medical management of donor
Optimal Medical Management of the Potential Organ Donor
• Continued intensity of support• Focus shift from cerebral protective strategies to
optimizing donor organs for transplantation• Simultaneous critical care to organs of multiple
patients• Critical period
• Facilitates donor somatic survival• Maintains organs to be procured best
condition• Donor management impact recipient function
Role of Clinical Care Team in Donation
• Donor Medical Management = Critical Care Management • Integrative multi-disciplinary collaborative
approach between OPO and Clinical Care Team
•Intensivists•Pulmonary Consultants•Cardiac Consultants•Nursing •Respiratory
• Donor Management Team/Defined Champions
• Donor Family Support
•Hemodynamics•Ventilatory Management•Echocardiography•Diagnostic Procedures
Cardiac Transplant Continuum
Mechanism•Catecholamine
Hypothesis
•Autonomic Surge
•MVO2 supply demand imbalance
•Endocrinopathy
Coronary perfusion
•Aerobic AnerobicNEURO
INJURY
BRAIN
DEATHDONOR
Approach•Standard •Pretreatment ?
•Sympathetic antagonists
•Calcium blockers
•Cardiac sympathectomy
•Fluids
•Immunomodulators catecholamines
•Vasopressin
•Thyroid hormone
•Steroids
•Insulin
Improvement of Donor Myocardial Function After Treatment of Autonomic Surge During Brain Death
Audibert Transplantation 2006;82:1031-1036
•Defined by Systolic BP > 200 mmkg and tachycardia > 140 beats/min.
•Observed in 63%
•Duration 1.2 hours (30 min-6hr)
•Followed by BP which never occurred when AS absent
•AS less with head injury
•Treated with esmolol, urapidil or nicardipine
•Treatment independently associated with EF > 50%
Complications of Brain Death and Impact on Organ Retrieval
“…hypothesized that brain death related complications would have no effect on the number of organs donated if an aggressive donor management protocol was in place.”
•Vasopressor requirement 97.1%
•Coagulopathy 55.1%
•Thrombocytopenia 53.6%
•Diabetes Insipidus 46.4%
•Cardiac ischemia 30.4%
•Lactic acidosis 24.6%
•Renal failure 20.3%
•ARDS 13%
Salim Am Surgeon 2006;72:377-381
Aggressive Donor Management and Organ Donor Shortage
Salim 2006;61:429-435
Transforming Unacceptable Donors
• 40% (21) MAP < 55 (mean 47 mmHg) despite inotropic support
• 19% (10) CVP > 15 (mean 18 mmHg)
• 4% (2) inotropes > 20 (mean 25 ug/Kg/min)
• 25% (13) PCWP > 15 (mean 20 mmHg)
• 12% (6) LVSWI < 15 (mean 12.8 gm)
• MAP > 60 mmHg
• CVP < 12 mmHg
• PCWP < 12 mmHg
• LVSWI > 15 gm
• Inotropes < 5 ug/Kg/mm
Potential Multi-organ Donors (150)
Unacceptable 35% (52) Acceptable 65% (98)
• Invasive monitoring
• Bolus steroids (15mg/Kg/MP)
• Insulin/glucose
• Argine vasopressin 1U bolus and 1.5 U/hr
• Tri-iodothyronine 4 ug bolus and 3 ug/hr
• 44/52 “unacceptable” donors yielded transplantable organs
• 84% alive (13-48 months)
• 92% of initially unacceptable organs were capable of functional resuscitation
Optimum Management Outcomes
Wheeldon J Heart Lung Txp 1995; 14:734-742
Donor Management TrialHormonal Therapy Randomization
T3 0.8 ug/Kg Bolus
Followed by 0.113
μg/Kg/hr
Methyl-prednisolone
1000 mg Bolus
T3 And Methyl-prednisolone
Placebo
Venkateswaran Eur Heart J 2009
Hemodynamic Effects of Adjunctive Hormonal Therapy
• Trauma 24%• Vascular event/tumor 64%• Hypoxia/Infection 13%
Brain Stem Death (80)
ManagementBrain Death
Coning Consent Management HRT Retrieval
1 hr 5.9 hrs10.7 hrs 2 hrs
12.7 hrs 6.9 hrs
19.6 hrsVenkateswaran Eur Heart J 2009
•MAP < 70 mmHg
with
•CVP or PCWP > 14 mmHg
and
•CI < 2.4 L/min
•Dopamine > 5 μg/Kg/min
or
•Norepi > 0.06 μg/Kg/min
or
•Epi > 0.03 μg/Kg/min
OR
•CVP < 12 mmHg
•PCWP < 14 mm Hg
•CI > 2.5 L/min
•Minimal vasoactive support
•No gross LVH or palpable CAD on inspection
MarginalFunctional
Venkateswaran Eur Heart J 2009
Hemodynamic Parameters for Entire Trial Cohort
Venkateswaran Eur Heart J 2009
Cardiac Index and Treatment
Venkateswaran Eur Heart J 2009
• 58% Low free T3 or T4
• 18% co-existent low TSH
• Initial CI no different with low T3 or T4
• CI ↑ regardless of initial T3 or T4 or T3 Tx
Donor Heart Function and Thyroid Function
Venkateswaran Eur Heart J 2009
Cardiac Index and Pre-Tx Thyroid
Donor Heart Function and Norepinephrine
• Association between NE withdrawal and cardiac functional improvement
• 60% (48/80) initially receiving NE• Significantly lower LVSWI (43.5 vs 36.6)• Vasopressin introduced 60/80 → NE withdrawn in
26/48 or reduced to 0.06 μg/Kg/min
CI 3.18 3.72
SVR 1190 964
Norepi Vasopressin
Venkateswaran Eur Heart J 2009
Hemodynamic Effects of Adjunctive Hormone Therapy
Trial Donors (80)
50% Non-Marginal at Initial Assess (40)
50% Marginal at Initial Assess (40)
35% Unsuitable at End Assessment (14)
•CAD (5)
•RV Dysfunction (5)
•LV Dysfunction (4)
65% Unsuitable at End Assessment (26)
•CAD (15)
•RV Dysfunction (6)
•LV Dysfunction (5)
65% Suitable at End
Assessment (26)
35% Suitable at End
Assessment (14)
58% Retrieved for TXP (15)
71% Retrieved for TXP (10)
Total Suitable at End Assessment (40)
63% Hearts Txp (25) 37% Non-Txp (15)
•No Recipient (10)
•Age > 60 (3)
•Poor Donor Txp (2)Venkateswaran Eur Heart J 2009
Donor Management
“Active donor management improves circulatory function and has the capacity to increase the yield of
suitable hearts from the existing pool of potential donors. Neither T3 nor MP,
alone or in combination, appears fundamental to this improvement.”
Venkateswaran Eur Heart J 2009
Donor Management
“Our study demonstrates that not only may donor circulatory status be improved by active management but also there is the potential to increase the yield of
transplantable hearts if decisions on organ acceptance are deferred until a period of resuscitation
and assessment is complete. Active donor management with PAFC monitoring is the
cornerstone of this objective but this has implications for planning donor retrieval services. The simple
introduction of hormone therapy is not a substitute for the detailed haemodynamic assessment and
management of the potential heart donor.”
Venkateswaran Eur Heart J 2009
Role of Brain Death in Donor Lung Injury
• “Blast Injury Theory” → Hemodynamic mechanism
• Sympathetic surge
• Transient massive ↑ hydrostatic pressure with structural damage to capillary endothelium
• Sympathetic alteration of capillary permeability
• Cytokines → TNF IL-1 activate endothelial cells to express adhesion molecules and mediate production of IL-8 → neutrophil activator → bind to endothelial cells → migrate to interstitium/alveolar spaces → release ROS and proteolytic enzymes
Neurogenic Pulmonary Edema
Inflammatory Response
Left
Right ↑ Pvc ↑ VR ↑PAP ↑Pul Volume
↑ SVR ↓CO ↑LAP
Alvonitis Trasnaplantation 2003; 75:1928-1933
Potential Lung Donor
• PaO2/FiO2 > 300
• PEEP = 5cmH2O• Clear chest x-ray• Age < 55• Tobacco < 20 pk/yr• Absence of trauma,
surgery, aspiration, secretions, malignancy purulent secretions
Ideal Lungs “Marginal” Lungs Unacceptable Lungs
Baseline Status
Acquired reversible
AspirationAlveolar Flooding
Atelactasis
Impact of Donor Management Protocol on Lung Donation and Recipient Outcomes
• Transplant Pulmonologists and OPO staff training sessions on Donor selection and management
• Emphasis upon every donor as a lung donor
• Request and consent should be attempted for every donor
• Education regarding donor management strategies
Angel AJRCCM 2006;174:710-716
Education
Impact of Donor Management Protocol on Lung Donation and Recipient Outcomes
• Recruitment Maneuvers
• Pressure control ventilation 25 cm H2O and PEEP 15 cm H2O for 2 hours
• Switch to conventional volume control mode with TV 10 ml/kg and PEEP 5 cm H2O
• Fluid balance• Minimized use of crystalloids• Diuretics to maintain neutral or negative balance
• Aspiration risk• Elevated head of bed to 300
• Inflate ET balloon to 25 cm H2O
• Bronchosopy with BAL to eval CXR area of infiltrate
Active Management
Angel AJRCCM 2006;174:710-716
Impact of Donor Management Protocol on Lung Donation and Recipient Outcomes
• PaO2/FIO2
> 300
• No infiltrates• No copious purulent
secretions• No bronchoscopically
demonstrated aspiration
• Age > 55 years• Pack years > 20• History of pulmonary
disease• Severe chest trauma• Mechanical ventilation >
4 days• Positive gram stain of
tracheal or BAL fluids
Absolute Extended
•Ideal•All absolute criteria•No extended criteria
•Extended•All absolute criteria•One or more extended criteria
•Poor•Did not satisfy ALL absolute criteria
Poor Ideal Poor Extended
Angel AJRCCM 2006;174:710-716
Impact of Donor Management Protocol on Lung Donation and Recipient Outcomes
Angel AJRCCM 2006;174:710-716
Impact of Donor Management Protocol on Lung Donation and Recipient Outcomes
Angel AJRCCM 2006;174:710-716
Early Donor Management Increases Retrieval Rate of Lung for TXP
Timing Within 2 hrs Consent Continued for 6.9 hrs
OR
Protocol optimization for vent/hemodynamics
Active management using protocols by on site team
Standard ICU approach
Pul Art. Cath 2 hours post consent OR
Fem – A Line 2 hours post consent OR
EVLWI Measured None
PVPI Calculated None
Bronchoscopy Early OR
Trial Meds 1 hour into management OR
TRIAL NON - TRIAL
Venkateswaran Ann Thorac Surg 2008; 85: 278-86
Early Donor Management Increases Retrieval Rate of Lungs for TXP
• Commenced Management• 2 hours post consent• 12.5 hours post brain death and continued for 6.9 hours
• Respiratory Management• Bronchoscopy early• TV 10 ml/Kg PEEP 5 cm H2O• Frequent Suctioning• Volume recruitment by turning every 2 hours
• Active hemodynamic management• Specific algorithms for
• CI > 2.5 L/min m2
• CVP and PCWP < 12 mm Hg• MAP 65-85• SVR 800-1200 dynes/cm/sec-5 → vasopressin
• Fluid Resuscitation• Small amount blood (Hgb > 10 g/dl), gelatin or colloid• 376 ml of colloid /27 ml crystaloid
Venkateswaran Ann Thorac Surg 2008; 85: 278-86
Management Points
Early Donor Management Increases Retrieval Rates of Lungs for TXP
• Respiratory function – deteriorated• ↓ PaO2/FIO2
• ↑ EVLWI and PVPI• PaO2/FIO2 rose after final inspection
• Bronchoscopy• Abnormalities in 20 donors• BAL positive cultures in 31 donors
• Methylprednisolone• No effect on any absolute indicator• Associated with reduced accumulation of EVLWI and lower pre-
retrieval PCWP• Did not improve EVLWI in marginal
• Norepinephrine → PaO2 / FIO2 ratio deteriorated and EVLWI increased significantly NOT prevented by withdrawal of NE
Management Outcomes
Venkateswaran Ann Thorac Surg 2008; 85: 278-86
Early Donor Management Increases Retrieval Rate for Lungs for TXP
Potential Lung Donors (182)
Trial Lungs (120)Non Trial Lungs (244)
T3 (34) Placebo (28) MP(30) T3 + MP(28)
Non-MP Lungs (62) MP Donors (58)
35.5% Lungs Retrieval (22/62)
44.8% Lungs Retrieval (26/58)
40% Lungs Transplanted (48/120)
27% Lungs Transplanted
(66/244)Venkateswaran Ann Thorac Surg 2008; 85: 278-86
Early Donor Management“Although nontrial donor care was based on a similar management protocol, albeit without bronchoscopy or invasive monitoring, management was overseen
by donor procurement coordinators, who are simultaneously engaged in a logistic process that
includes acquisition of consent, donor family support, offering of organs to recipient centers,
arranging the multiorgan retrieval procedure, and transportation of organs and tissue. In contrast, the donor research fellow was wholly dedicated to donor
management, and we would suggest that this dedicated donor management role is fundamental to
maximize yield.”Venkateswaran Ann Thorac Surg 2008; 85: 278-86
3.75 OPD3.75 OPD
Subtle Changes or Paradigm Subtle Changes or Paradigm Shift?Shift?
Joseph Kambe, M.D.Joseph Kambe, M.D.
Improving What We Do.Improving What We Do.
There are short term goals and long term There are short term goals and long term goals.goals.
3.75 Organs per Donor is a short term goal.3.75 Organs per Donor is a short term goal. Multiple hospitals have shown this is attainable.Multiple hospitals have shown this is attainable. In reality, by paying attention to detail.In reality, by paying attention to detail.
Why it happened is not so clear.Why it happened is not so clear. Improved because we were looking?Improved because we were looking? Is it sustainable across multiple institutions?Is it sustainable across multiple institutions?
Donor Management GoalsDonor Management Goals
If all are met, great results.If all are met, great results. If only some are met, variable results.If only some are met, variable results.
As an example: CVP and C.O. (BP).As an example: CVP and C.O. (BP). If you met the CVP goal and not use If you met the CVP goal and not use
pressors.pressors. Does this mean you did something useful?Does this mean you did something useful? Or does it mean that the cardio/pulmonary Or does it mean that the cardio/pulmonary
axis was intrinsically good anyway? Or both?axis was intrinsically good anyway? Or both?
How Useful is a CVP?How Useful is a CVP?
What affects the CVP?What affects the CVP? Volume?Volume? Cardiac Status?Cardiac Status? Pulmonary Status?Pulmonary Status? Fluids being infused?Fluids being infused? Patient position?Patient position? Who does the measurement?Who does the measurement? Vasomotor tone?Vasomotor tone?
The Computer: CVP = 17The Computer: CVP = 17
Would you diurese this patient?
CVP should estimate dLVPCVP should estimate dLVP
CVP will be falsely high.Positive pressure ventilation.PEEP.Pulmonary disease.
The Clinical PictureThe Clinical Picture
PEEP = 12 cm HPEEP = 12 cm H22O.O. BP = 105/50 mmHg.BP = 105/50 mmHg. CI = 2.3 l/min/mCI = 2.3 l/min/m22..
Vasoactive Drugs - GoalsVasoactive Drugs - Goals
Blood Pressure or Cardiac Output or Both.Blood Pressure or Cardiac Output or Both. One organ perfuses by pressure alone.One organ perfuses by pressure alone.
HEART: diastolic root pressure - ventricular HEART: diastolic root pressure - ventricular wall tension.wall tension.
Increase myocardial OIncrease myocardial O22 Consumption Consumption
All other organs are cardiac output All other organs are cardiac output dependent.dependent. There is a point where pressure comes at the There is a point where pressure comes at the
expense of perfusion.expense of perfusion.
Vasoactive DrugsVasoactive Drugs
Dopamine:Dopamine: Highest incidence of arrhythmias, organ Highest incidence of arrhythmias, organ
dysfunction, death.dysfunction, death. Causes norepinephrine release from the Causes norepinephrine release from the
storage granules in the synapse.storage granules in the synapse. Does not increase renal blood flow.Does not increase renal blood flow. Acts as the antagonist to Renin-Angiotension.Acts as the antagonist to Renin-Angiotension. Recent articles in CCM argue that it should Recent articles in CCM argue that it should
not be used.not be used.
NorepinephineNorepinephine
Activity depends on the number of alpha Activity depends on the number of alpha and beta receptors in the target organ.and beta receptors in the target organ.
Under stimulation receptors are used Under stimulation receptors are used up.up.
Only vasoactive drug we do not dose by Only vasoactive drug we do not dose by weight. weight. Why I know not.Why I know not.
NeosynephrineNeosynephrine
Pure alpha agonist.Pure alpha agonist. Causes peripheral vasoconstriction.Causes peripheral vasoconstriction. In neurogenic shock: there is peripheral In neurogenic shock: there is peripheral
vasoconstriction and cardiac depression.vasoconstriction and cardiac depression. After-load increase = increased wall tension.After-load increase = increased wall tension.
Hormone ReplacementHormone Replacement
N = 701N = 701
Historical Historical ControlControl
Non-Non-HormoneHormone
ReplacementReplacement
HormoneHormone
ReplacementReplacement
Age Age << 40 40 3.8 opd3.8 opd 4.2 opd4.2 opd
Age > 40Age > 40 2.5 opd2.5 opd 3.1 opd3.1 opd
So, Why Is this So, Why Is this Controversial?Controversial?
Repeating this has been Repeating this has been difficult/impossible.difficult/impossible. Used TUsed T33, most of us use T, most of us use T44.. These patients were all fed.These patients were all fed. The Company says TThe Company says T44 is not stable in D is not stable in D55W.W.
The Company says TThe Company says T44 is not stable as an is not stable as an infusion.infusion. As of now there is no data about these issues As of now there is no data about these issues
from the Company.from the Company.
Conversion of TConversion of T44
TT44 is not the active hormone. is not the active hormone.
TT44 must be converted to T must be converted to T33 in the in the periphery.periphery.
This conversion is decreased in illness.This conversion is decreased in illness. May take up to 8 hours.May take up to 8 hours.
Has an immediate action on vasomotor Has an immediate action on vasomotor tone.tone.
Actions of TActions of T33
Intracellular TIntracellular T33 Activity Activity
TT33 Action in the Nucleus Action in the Nucleus
Increases RNA transcription/protein Increases RNA transcription/protein synthesis.synthesis. Increases Glucose and protein metabolism.Increases Glucose and protein metabolism.
Where does the fuel for this come from?Where does the fuel for this come from? Remember in the original article, all were fed.Remember in the original article, all were fed. We have lost the ability to convert fat into glucose.We have lost the ability to convert fat into glucose. Burning intrinsic protein to make energy.Burning intrinsic protein to make energy.
In illness, studies show giving TIn illness, studies show giving T44.. Increases organ dysfunction and mortality.Increases organ dysfunction and mortality.
FurthermoreFurthermore
How critical is the 6 – 8 hour delay in THow critical is the 6 – 8 hour delay in T33 function in terms of repair (protein function in terms of repair (protein synthesis)?synthesis)? Should we all be using TShould we all be using T33??
In terms of protein metabolism.In terms of protein metabolism. Robbing Peter to pay Paul.Robbing Peter to pay Paul. Protein breakdown to generate energy.Protein breakdown to generate energy.
Given the Company’s guidelines.Given the Company’s guidelines. Are we even giving adequate amounts?Are we even giving adequate amounts?
So. What to Make of This?So. What to Make of This?
If we are going to use parameters.If we are going to use parameters. Education. Everyone needs to do it the Education. Everyone needs to do it the
same way.same way. Does it matter? How are we going to find Does it matter? How are we going to find
out?out? What to do about hormone replacement?What to do about hormone replacement? Do we need to upgrade our technology?Do we need to upgrade our technology?
There are noninvasive ways to measure C.O.There are noninvasive ways to measure C.O. Other ways to estimate LV filling pressure.Other ways to estimate LV filling pressure.
Plea for a National Plea for a National Database.Database.
Old medical axiom: WNL = we never Old medical axiom: WNL = we never looked.looked.
If you don’t measure it, you can’t improve it.If you don’t measure it, you can’t improve it. Critical Care has spend a lifetime looking.Critical Care has spend a lifetime looking. DMG’s are a beginning to this end.DMG’s are a beginning to this end.
We need to refine these.We need to refine these. The larger the numbers the better the accuracy.The larger the numbers the better the accuracy.
DONOR MANAGEMENT GOALS:Moving Toward a National Strategy
NIL Get Connected WebinarOctober 13, 2009
Darren Malinoski, MDAssistant Professor of Surgery
Director, Surgical Intensive Care UnitChair, Organ Donor Council
University of California, Irvine
BACKGROUND
• Donor Management Forum – August 2009– Intensivists, Transplant Surgeons, OPO representatives,
National Organizations
• Four predominant REQUESTS:1.Increase Intensivist involvement2.Increase the science of donor management3.Tie donor management data to SRTR outcomes4.Funding for research
PLAN FOR THIS SESSION
• Background on Donor Management Goals (DMGs)• Region 10• Region 5 DMG initiative• Survey Monkey results• National DMG initiative
OTPD and DMGs
2
2.2
2.4
2.6
2.8
3
3.2
3.4
3.6
Nov-07 Dec-07 Jan-08 Feb-08
OTPD when DMGsmet
OTPD when DMGsNOT met
OTPD Total
CONSENSUS 1 -- 4
• Sodium < 155• MAP > 60• pH 7.25 – 7.5• CVP < 10
(or serum osmolality 285 – 295)
CONSENSUS 5 & 6
• Pressors 1 or none
(one pressor plus Vasopressin
to treat DI is OK)
• pO2 > 300 if on 100% O2
( or a P/F ratio > 3)
RESULTS FULL YEAR 2008
• 774 TOTAL CASES
• 264 Met Criteria = 34%
• 510 Did not meet criteria = 66%
INCREASE IN ORGANS TRANSPLANTED PER DONOR WHEN DONOR MANAGEMENT GOALS ARE MET
SORTED BY DONOR TYPE UNOS REGION 10
1.36
0.150.591.77
1
1.5
2
2.5
3
3.5
4
4.5
5
SCD ECD DCD TOT
OR
GA
NS
PE
R D
ON
OR
DONOR MANAGEMENT GOALS:DONOR MANAGEMENT GOALS:The Region 5 DMG ProjectThe Region 5 DMG Project
Part 1: RetrospectivePart 1: RetrospectivePart 2: ProspectivePart 2: Prospective
PROPOSED DMG’S for REGIONPROPOSED DMG’S for REGION 1. MAP 60-1001. MAP 60-100
2. CVP 4-102. CVP 4-10 3. EF > 50%3. EF > 50% 4. </= 1 pressor used AND:4. </= 1 pressor used AND: a. Dopamine </= 10 mcg/kg/mina. Dopamine </= 10 mcg/kg/min
b. b. Neosynephrine </= 100 mcg/kg/minNeosynephrine </= 100 mcg/kg/min c. Norepinephrine </= 10 mcg/kg/minc. Norepinephrine </= 10 mcg/kg/min d. Vasopressin </= 2.4 units/hour (0.04 units/min)d. Vasopressin </= 2.4 units/hour (0.04 units/min)
5. ABG pH 7.3-7.455. ABG pH 7.3-7.45 6. 6. Pao2:Fio2 ratio >300 on PEEP = 5Pao2:Fio2 ratio >300 on PEEP = 5
7. Serum Sodium 135-1607. Serum Sodium 135-160 8. Urine output 1-3 cc/kg/hour 8. Urine output 1-3 cc/kg/hour 9. Glucose < 150 9. Glucose < 150 10. Hemoglobin > 10 10. Hemoglobin > 10
Track hormone replacement usageTrack hormone replacement usage
PART 1 - RETROSPECTIVEPART 1 - RETROSPECTIVE
Universal templateUniversal template 40 SCD’s from each OPO40 SCD’s from each OPO Retrospective collection of data regarding Retrospective collection of data regarding
proposed DMG’s (prior to procurement) and proposed DMG’s (prior to procurement) and organ disposition informationorgan disposition information
Statistical analyses:Statistical analyses:– 80% DMG’s = goal met80% DMG’s = goal met– >/= 4 OTPD = primary outcome measure>/= 4 OTPD = primary outcome measure– DMG-specific resultsDMG-specific results– Other notable findingsOther notable findings
DMG’S AND OTPDDMG’S AND OTPD Mean # DMG’s with >/= 4 OTPD = 7.2Mean # DMG’s with >/= 4 OTPD = 7.2 Mean # DMG’s with < 4 OTPD = 6.1 Mean # DMG’s with < 4 OTPD = 6.1
– T-test: p<0.001T-test: p<0.001
When “goals met” When “goals met” – Mean OTPD = 4.4Mean OTPD = 4.4– 70% >/= 4 OTPD70% >/= 4 OTPD
When “goals not met” When “goals not met” – Mean OTPD = 3.3 (t-test, p<0.001)Mean OTPD = 3.3 (t-test, p<0.001)– 39% >/=4 OTPD (Pearson’s Chi-square, p<0.001)39% >/=4 OTPD (Pearson’s Chi-square, p<0.001)
Multivariate analysis - >/= 4 OTPDMultivariate analysis - >/= 4 OTPD
VariableVariable OROR 95% CI95% CI p valuep value
ageage 0.950.95 0.93-0.970.93-0.97 <0.001<0.001
CVP 4-10CVP 4-10 1.71.7 0.96-3.10.96-3.1 0.0710.071
EF > 50%EF > 50% 4.54.5 2.5-8.32.5-8.3 <0.001<0.001
</1 pressor</1 pressor 1.0061.006 0.51-1.980.51-1.98 0.9860.986
P:F > 300P:F > 300 4.84.8 2.6-8.62.6-8.6 <0.001<0.001
Na 135-160Na 135-160 2.72.7 0.99-7.40.99-7.4 0.0530.053
Thyroid hormoneThyroid hormone 1.71.7 0.97-30.97-3 0.0670.067
Serum creatinineSerum creatinine 0.6120.612 0.4-0.930.4-0.93 0.0220.022
Moving Forward – Current ProjectMoving Forward – Current Project
The Region agreed on 9 The Region agreed on 9 DMG’s to prospectively DMG’s to prospectively implement and track for 6 implement and track for 6 months. months.
DMG’s will be measured at DMG’s will be measured at consent, 12-18 hours later, consent, 12-18 hours later, and prior to going to ORand prior to going to OR
OTPD and graft outcome OTPD and graft outcome data will be analyzed data will be analyzed
MAP > 60MAP > 60 CVP 4-10CVP 4-10 EF > 50%EF > 50% </= 1 pressor and low </= 1 pressor and low
dose (vasoP eliminated)dose (vasoP eliminated) pH 7.3-7.45pH 7.3-7.45 P:F > 300P:F > 300 Sodium 135-155*Sodium 135-155* Glucose < 150Glucose < 150 UOP 1-3 cc/kg/hr over UOP 1-3 cc/kg/hr over
preceding 4 hourspreceding 4 hours
General DataGeneral Data
Part 1Part 1 320 donors 320 donors 100% SCD100% SCD DMG’s prior to OR DMG’s prior to OR Purely retrospective Purely retrospective
datadata DMG’s met = 8/10DMG’s met = 8/10
Part 2 – July-Dec 2008Part 2 – July-Dec 2008 492 donors492 donors 380 (77%) SCD380 (77%) SCD DMG’s at 3 time pointsDMG’s at 3 time points Prospective Prospective
implementationimplementation DMG’s met = 7/9DMG’s met = 7/9 Graft Function DataGraft Function Data
Can we make a difference or is Can we make a difference or is fate sealed before we start?fate sealed before we start?
DMG data DMG data (SCD’s only – (SCD’s only – n=255)n=255)
<4 OTPD <4 OTPD (n=132)(n=132)
>/=4 OTPD >/=4 OTPD (n=123)(n=123)
p value p value
DMG’s at consent (1)DMG’s at consent (1) 4.5 5 0.001
DMG’s at 12-18 hrs (2)DMG’s at 12-18 hrs (2) 5.1 6.1 <0.001
DMG’s prior to OR (3)DMG’s prior to OR (3) 5.5 6.3 <0.001
Delta DMG 1-2Delta DMG 1-2 0.71 1.1 0.050
Delta DMG 2-3Delta DMG 2-3 0.3 0.19 0.522
Delta DMG 1-3Delta DMG 1-3 1 1.3 0.210
Multivariate analysis – Part 2Multivariate analysis – Part 2>/= 4 OTPD (n=376, 4 missing)>/= 4 OTPD (n=376, 4 missing)
VariableVariable OROR 95% CI95% CI p valuep value
Age 0.95 0.93-0.96 <0.001
Terminal creatinine
0.74 0.6-0.9 0.004
DMG 1 met 1.9 1.02-3.7 0.044
DMG 2 met 1.6 0.92-2.6 0.097
DMG 3 met 2.2 1.3-3.6 0.002
Ejection fraction 3 3.3 1.8-6 <0.001
Pao2:Fio2 3 3.2 1.6-6 0.001
PART 2 CONCLUSIONSPART 2 CONCLUSIONS
DMG’s are still associated with OTPDDMG’s are still associated with OTPD
Changes in DMG’s over time are associated Changes in DMG’s over time are associated with OTPDwith OTPD
Pre-donor management is associated with Pre-donor management is associated with outcomesoutcomes
SURVEY MONKEY RESULTS41 OPO’s responding…
Does your OPO use DMGs?
Does your region have a uniform DMG initiative?
• 38 responses– YES: 25 (66%)– NO: 13 (34%)
• More than one response from 9 regions– One response from region1– No response from region 6
If your region does not have uniform DMGs, would you be willing to do so?
Would your OPO be interested in participating in a National DMG Project?
How important is a National DMG initiative for advancing the science of donor care?
CONCLUSIONS
• REGION 10: – Retrospective: Meeting all six DMG’s prior to the OR
more OTPD
• REGION 5:– Retrospective and Prospective data suggest that meeting
DMG’s throughout case more OTPD
• National Survey suggests strong support for DMG’s and a donor database
Future DirectionsRefine DMG’s
Develop Web-based data entry system
Create national DMG’s and donor database
Continue to engage intensivist community
Create a network for large-scale research