Presentation on theme: "DMG Update UNOS Region 5 Collaborative"— Presentation transcript:
1DMG Update UNOS Region 5 Collaborative December 12, 2012Darren Malinoski, MDMegan Crutchfield, MPHSection of Surgical Critical CarePortland VA Medical Center
2Questions to Run OnDo these data raise any questions or research ideas?How will you use this information moving forward?I would like to thank all of the members of the region 5 DMG workgroup and would be happy to entertain any questions.
3The History of DMGs in Region 5 Phase 1 – retrospective – 10 DMGs2007Prior to recovery320 donorsPhase 2 – prospective – 9 DMGsJuly 2008 – July 2010Three time points914 donorsPhase 3 – prospective – modified the 9 DMGsAug 2010 – Feb 2012Four time points1684 donorsPhase 4 – The WEB PORTAL…
5UNOS Region 5 DMG Web Portal Launched in March – supported by Tii Linked to DonorNetForced field entryGenerates reportsRecipient data added by TiiFields for study data
6Regional Update Phase 4 – THE WEB PORTAL Same DMGs as Phase 3 DMGs at four time pointsNovel parameters: SVV/PPV/swan-ganzAutomatic calculations and forced field entriesBMI, donor hospital, registry, and research sectionsOutcome data added dailyMarch 2012 through September 2012
9The History of DMGs in Region 5 Phase 1 – retrospective – 10 DMGsDMGs met in 30%Phase 2 – prospective – 9 DMGsDMGs met in 13%, 29%, and 34%Phase 3 – prospective – modified DMGsDMGs 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)
11Association between meeting the DMG Bundle and OTPD OTPD WHEN DMGs NOT MET VS MET AT EACH TIME POINTREFERRALAUTHORIZATION12-18 HOURSPRIOR TO ORNOT METMETPhase 1---3.344.35Phase 23.283.923.103.993.024.04Phase 33.383.353.253.802.873.872.533.88Phase 43.223.833.132.42Go to 2 decimal points for OTPD and no SD. Bold the ones that have a p <0.05*(DCDDs and DNDDs used in phase 4), statistics not done yet
12DMG web portal next steps DMG Workgroup ConsiderationsAdd pediatric DMGsModify existing DMGsGlucose thresholdAdd insulin dosagesModify report formatAdd other OPOs
13Association between Different Glucose thresholds and OTPD OTPD WHEN GLUCOSE LEVEL MET VS NOT MET AT EACH TIME POINTREFERRALAUTHORIZATION12-18 HOURSPRIOR TO OROTPDp< 1503.410.9893.450.2363.470.4500.200> 1503.353.423.39< 1800.1620.4493.440.7373.480.015> 1803.343.29< 2003.460.1020.4100.2590.006> 2003.323.403.383.21
15HRSA Mild Hypothermia RCT HRSA-funded multi-OPO randomized controlled trialIntervention: Mild Hypothermia (34-35C) vs. Normothermia ( ) for > 12 hrs prior to organ recoveryMain outcome measures: DGF and SGFInclusion criteria: hemodynamically stable abdominal organ donors
16HRSA Mild Hypothermia RCT Enrolled 123 Donors since March 15th4 hypothermic donors with adverse eventsHypokalemia <3.0 x 2Arrhythmia – SVT and a.fib x 3Afib – intermittent prior to BD, spontaneous conversion after K replaced (dropped to 2.9)SVT – short run during prep in ORNow replace K to 3.5 prior to enrollment and maintainPEA arrest and rapid recovery of organs in Normothermia group*No hemodynamic instability in Hypothermia group
17HRSA Mild Hypothermia RCT Challenges:Determining when thoracic organs have been ruled outOptimal notification of recipient centersNext Steps:Propose expansion to all research-authorized DNDDs – add thoracic donorsTrend towards increase in PaO2:FiO2 over time in hypothermia group (299 to 330, p=0.08)22 Lungs and 12 Hearts
23- In press with the American Journal of Transplantation VariableOR95% CIpAge (per year)1.020.003Creatinine prior to recovery (per mg/dL)1.40.001ECD0.90.664Cold ischemia time (per hour)1.030.011DMGs met at consent0.50.019- In press with the American Journal of Transplantation
24Registered Organ Donors Receive Similar Levels of Intensive Care from Donor Hospitals Compared to Non-Registered Donors: An Opportunity to Increase Public Intent to DonateIntent to donate affected by perception that patients with “pink dot” on license will receive less care from doctorsObjective: compare the rate of “meeting DMGs” between registered and non-registered donors
25Not on State Registry (n=489) 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[all donors included]Not on State Registry (n=489)On State Registry (n=144)p valueDMGs met at referral9%0.846DMGs met at consent22%20%0.655DMGs met hours48%52%0.334DMGs met prior to OR58%69%0.019OTPD0.104-presented at 2012 ATC
26ConclusionsPatients 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.
29Variables Associated with Liver Graft Transplantation Lower AgeLower BMIMale GenderSCD status (vs. ECD)Higher MAPLower CVPHigher Ejection FractionHigher PaO2:FiO2Lower GlucoseVasopressin useTo summarize, variables seen to associate with graft transplantation are: the donor demographics of Lower Age and BMI, Male Gender and SCD status ;And the critical care values of Higher MAP, Lower CVP, Higher Ejection Fraction; better oxygenation ratios; Lower Glucose; and the use of Vasopressin
30Variables Associated with Liver Graft Discard From 873 Procured livers…730 Livers Transplanted,143 Livers Discarded (16%)We turned to look at associations with liver graft discards. These were organs which were procured, but ultimately not used for transplant, most likely upon inspection by the transplant surgeons. And of 873 livers, 730 were used
31Variables Associated with Liver Graft Discard Older AgeHigher BMIFemale GenderECD status (vs. SCD)Higher CVPLower Urine OutputLower PaO2:FiO2Lower thyroid hormone dosagesThe variables we found associated with graft discard wereThe demographics of Older Age and higher BMI, Female Gender, Extended Criteria Donor status, Higher CVP, Lower Urine Output, worse pulmonary function, Lower doses of thyroid hormone
32Variables Associated with Liver Graft Survival 730 Livers Transplanted694 (95%) survival after 74±73 daysFinally we analyzed the livers were used for transplant, which were 730 in number. At a mean follow-up of 74 days ( and some had much longer follow up) 95% of grafts were still functioning.These grafts were associated with the Donor demographics of lower age, lower BMI and SCD status. Gender was not important.VariableGraft Survival vs. FailureAge (years)38 vs. 44BMI (kg/m2)26 vs. 30SCD96% vs. 91%Male Gender96% vs. 94%
33Variables Associated with Liver Graft Survival Cold Ischemia Time did not differ7.4 vs. 7.7 hours, p=0.675None of the critical care endpoints or medications were associated with graft survivalIn this analysis, the cold ischemia time did not differ between surviving and failing grafts.But what was interesting was that none of the DMGs obtained, or medications used were associated with graft survival. Does that mean that nothing I do in the ICU can impact on graft survival? It is possible that the care provided across the board is becoming increasingly more uniform, and there were few donors with only very low numbers of critical care endpoints met. Its also likely that transplant surgeons are getting more experience at rejecting organs that are likely to fail, because the overall failure rate of 5% is low. I’d like to think that, The selection process may have already chosen for livers managed well, and so they went on to do well.Clearly Important, recipient medical demographics and are not included in this analysis
34ConclusionsDonor age, BMI, SCD status, and gender are associated with both liver graft transplantation and discard ratesLower donor age, BMI, and SCD status are associated with graft survival ratesAmong the fixed Donor characteristics, we found that Donor Age, BMI, SCD, and gender were associated with both graft utilization and graft discard ratesBut among the organs then selected for transplant, only donor age, BMI, and SCD are associated with graft survival.
38Questions to Run OnDo these data raise any questions or research ideas?How will you use this information moving forward?I would like to thank all of the members of the region 5 DMG workgroup and would be happy to entertain any questions.