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


Hemodynamic Parameters for Entire Trial Cohort


Cardiac Index and Treatment


• 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


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


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.”


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.”


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


• 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


• 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


Angel AJRCCM 2006;174:710-716


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


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


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

http://images.google.com/imgres?imgurl=http://www.mayoclinic.org/transplant/images/donate-life-162.gif&imgrefurl=http://www.mayoclinic.org/transplant/organ-donation.html&h=151&w=162&sz=4&hl=en&start=32&tbnid=qr4LT3Bw5uI0YM:&tbnh=91&tbnw=98&prev=/images?q=organ+donation&start=20&ndsp=20&svnum=10&hl=en&lr=&sa=N

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

Documents

Management of the Potential Organ Donor