Presentation is loading. Please wait.

Presentation is loading. Please wait.

DMG Update UNOS Region 5 Collaborative December 12, 2012 Darren Malinoski, MD Megan Crutchfield, MPH Section of Surgical Critical Care Portland VA Medical.

Similar presentations


Presentation on theme: "DMG Update UNOS Region 5 Collaborative December 12, 2012 Darren Malinoski, MD Megan Crutchfield, MPH Section of Surgical Critical Care Portland VA Medical."— Presentation transcript:

1 DMG Update UNOS Region 5 Collaborative December 12, 2012 Darren Malinoski, MD Megan Crutchfield, MPH Section of Surgical Critical Care Portland VA Medical Center

2 Questions to Run On Do these data raise any questions or research ideas? How will you use this information moving forward?

3 The History of DMGs in Region 5 Phase 1 – retrospective – 10 DMGs 2007 Prior to recovery 320 donors Phase 2 – prospective – 9 DMGs July 2008 – July 2010 Three time points 914 donors Phase 3 – prospective – modified the 9 DMGs Aug 2010 – Feb 2012 Four time points 1684 donors Phase 4 – The WEB PORTAL…

4

5 UNOS Region 5 DMG Web Portal Launched in March – supported by Tii Linked to DonorNet Forced field entry Generates reports Recipient data added by Tii Fields for study data

6 Regional Update Phase 4 – THE WEB PORTAL Same DMGs as Phase 3 DMGs at four time points Novel parameters: SVV/PPV/swan-ganz Automatic calculations and forced field entries BMI, donor hospital, registry, and research sections Outcome data added daily March 2012 through September 2012

7 Regional Update – Phase donors (94% of donors in Unet) 534 SCD 181 ECD 92 DCD 3.23 OTPD (all donors) SCD – 3.78 ECD – 2.35 DCD – 2.02

8 Phase 4 – organ utilization

9 The History of DMGs in Region 5 Phase 1 – retrospective – 10 DMGs DMGs met in 30% Phase 2 – prospective – 9 DMGs DMGs met in 13%, 29%, and 34% Phase 3 – prospective – modified DMGs DMGs met in 9%, 21%, 48%, and 59% Phase 4 – the WEB PORTAL… DMGs met in 13%, 19%, 42%, and 60%* *(DCDDs and DNDDs used in phase 4)

10 Web Portal Reports

11 Association between meeting the DMG Bundle and OTPD OTPD WHEN DMGs NOT MET VS MET AT EACH TIME POINT REFERRALAUTHORIZATION12-18 HOURSPRIOR TO OR NOT MET MET NOT MET MET NOT MET MET NOT MET MET Phase Phase Phase Phase *(DCDDs and DNDDs used in phase 4), statistics not done yet

12 DMG web portal next steps DMG Workgroup Considerations Add pediatric DMGs Modify existing DMGs Glucose threshold Add insulin dosages Modify report format Add other OPOs

13 Association between Different Glucose thresholds and OTPD OTPD WHEN GLUCOSE LEVEL MET VS NOT MET AT EACH TIME POINT REFERRALAUTHORIZATION12-18 HOURSPRIOR TO OR OTPDp p p p < > < > < >

14 Published/presented/ongoing research projects

15 HRSA Mild Hypothermia RCT HRSA-funded multi-OPO randomized controlled trial Intervention: Mild Hypothermia (34-35C) vs. Normothermia ( ) for > 12 hrs prior to organ recovery Main outcome measures: DGF and SGF Inclusion criteria: hemodynamically stable abdominal organ donors

16 HRSA Mild Hypothermia RCT Enrolled 123 Donors since March 15 th 4 hypothermic donors with adverse events Hypokalemia <3.0 x 2 Arrhythmia – SVT and a.fib x 3 Afib – intermittent prior to BD, spontaneous conversion after K replaced (dropped to 2.9) SVT – short run during prep in OR Now replace K to 3.5 prior to enrollment and maintain PEA arrest and rapid recovery of organs in Normothermia group *No hemodynamic instability in Hypothermia group

17 HRSA Mild Hypothermia RCT Challenges: Determining when thoracic organs have been ruled out Optimal notification of recipient centers Next Steps: Propose expansion to all research-authorized DNDDs – add thoracic donors Trend towards increase in PaO2:FiO2 over time in hypothermia group (299 to 330, p=0.08) 22 Lungs and 12 Hearts

18

19

20

21 DMG/Variable OR (>4 OTPD)95% CIp value Continuous Variables Age (years) – 0.966< Creatinine (mg/dL) – Categorical Variables Thyroid Hormone use – CVP 4 – 10 mmHg – EF > 50% – 7.592< P:F > 300 on PEEP – 8.506< Na 135 – 160 mEq/L – Goals met – 7.732< 0.001

22

23 - In press with the American Journal of Transplantation

24 Registered Organ Donors Receive Similar Levels of Intensive Care from Donor Hospitals Compared to Non-Registered Donors: An Opportunity to Increase Public Intent to Donate Intent to donate affected by perception that patients with pink dot on license will receive less care from doctors Objective: compare the rate of meeting DMGs between registered and non-registered donors

25 [all donors included]Not on State Registry (n=489) On State Registry (n=144) p value DMGs met at referral9% DMGs met at consent22%20%0.655 DMGs met hours48%52%0.334 DMGs met prior to OR58%69%0.019 OTPD Registered Organ Donors Receive Similar Levels of Intensive Care from Donor Hospitals Compared to Non-Registered Donors: An Opportunity to Increase Public Intent to Donate -presented at 2012 ATC

26 Conclusions Patients who are registered to be organ donors and suffer devastating brain injuries appear to receive the same level of critical care support from their healthcare providers prior to their intent to donate being established as those who are not registered to be organ donors. Registered donors are more likely to meet pre-determined critical care endpoints of resuscitation after consent for organ donation.

27

28

29 Variables Associated with Liver Graft Transplantation Lower Age Lower BMI Male Gender SCD status (vs. ECD) Higher MAP Lower CVP Higher Ejection Fraction Higher PaO 2 :FiO 2 Lower Glucose Vasopressin use

30 Variables Associated with Liver Graft Discard From 873 Procured livers… 730 Livers Transplanted, 143 Livers Discarded (16%)

31 Variables Associated with Liver Graft Discard Older Age Higher BMI Female Gender ECD status (vs. SCD) Higher CVP Lower Urine Output Lower PaO 2 :FiO 2 Lower thyroid hormone dosages

32 Variables Associated with Liver Graft Survival 730 Livers Transplanted 694 (95%) survival after 74±73 days VariableGraft Survival vs. Failure Age (years)38 vs. 44 BMI (kg/m 2 )26 vs. 30 SCD96% vs. 91% Male Gender96% vs. 94%

33 Variables Associated with Liver Graft Survival Cold Ischemia Time did not differ 7.4 vs. 7.7 hours, p=0.675 None of the critical care endpoints or medications were associated with graft survival

34 Conclusions Donor age, BMI, SCD status, and gender are associated with both liver graft transplantation and discard rates Lower donor age, BMI, and SCD status are associated with graft survival rates

35

36

37

38 Questions to Run On Do these data raise any questions or research ideas? How will you use this information moving forward?


Download ppt "DMG Update UNOS Region 5 Collaborative December 12, 2012 Darren Malinoski, MD Megan Crutchfield, MPH Section of Surgical Critical Care Portland VA Medical."

Similar presentations


Ads by Google