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Management of the Potential Organ Donor Kenneth E. Wood, D.O. Professor of Medicine and Anesthesiology Senior Director of Medical Affairs Director of Critical.

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Presentation on theme: "Management of the Potential Organ Donor Kenneth E. Wood, D.O. Professor of Medicine and Anesthesiology Senior Director of Medical Affairs Director of Critical."— Presentation transcript:

1 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

2 Disclaimer No Financial Support Slides Available by Request

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4 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

5 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

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8 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

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10 Cardiac Transplant Continuum Mechanism Catecholamine Hypothesis Autonomic Surge MVO 2 supply demand imbalance Endocrinopathy  Coronary perfusion Aerobic  Anerobic NEURO INJURY BRAIN DEATH DONOR Approach StandardPretreatment ? Sympathetic antagonists Calcium blockers Cardiac sympathectomy Fluids Immunomodulators catecholamines Vasopressin Thyroid hormone Steroids Insulin

11 Improvement of Donor Myocardial Function After Treatment of Autonomic Surge During Brain Death Audibert Transplantation 2006;82: 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%

12 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:

13 Aggressive Donor Management and Organ Donor Shortage Salim 2006;61:

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23 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:

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25 Donor Management Trial Hormonal Therapy Randomization T ug/Kg Bolus Followed by μ g/Kg/hr Methyl- prednisolone 1000 mg Bolus T 3 And Methyl- prednisolone Placebo Venkateswaran Eur Heart J 2009

26 Hemodynamic Effects of Adjunctive Hormonal Therapy Trauma 24% Vascular event/tumor 64% Hypoxia/Infection 13% Brain Stem Death (80) Management Brain Death Coning ConsentManagementHRTRetrieval 1 hr5.9 hrs10.7 hrs2 hrs 12.7 hrs6.9 hrs 19.6 hrs Venkateswaran 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 Marginal Functional

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28 Venkateswaran Eur Heart J 2009 Hemodynamic Parameters for Entire Trial Cohort

29 Venkateswaran Eur Heart J 2009 Cardiac Index and Treatment

30 Venkateswaran Eur Heart J % Low free T 3 or T 4 18% co-existent low TSH Initial CI no different with low T 3 or T 4 CI ↑ regardless of initial T 3 or T 4 or T 3 Tx Donor Heart Function and Thyroid Function

31 Venkateswaran Eur Heart J 2009 Cardiac Index and Pre-Tx Thyroid

32 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 SVR NorepiVasopressin Venkateswaran Eur Heart J 2009

33 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

34 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 T 3 nor MP, alone or in combination, appears fundamental to this improvement.” Venkateswaran Eur Heart J 2009

35 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

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37 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:

38 Potential Lung Donor PaO 2 /FiO 2 > 300 PEEP = 5cmH 2 O 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 Aspiration Alveolar Flooding Atelactasis

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41 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: Education

42 Impact of Donor Management Protocol on Lung Donation and Recipient Outcomes Recruitment Maneuvers Pressure control ventilation 25 cm H 2 O and PEEP 15 cm H 2 O for 2 hours Switch to conventional volume control mode with TV 10 ml/kg and PEEP 5 cm H 2 O Fluid balance Minimized use of crystalloids Diuretics to maintain neutral or negative balance Aspiration risk Elevated head of bed to 30 0 Inflate ET balloon to 25 cm H 2 O Bronchosopy with BAL to eval CXR area of infiltrate Active Management Angel AJRCCM 2006;174:

43 Impact of Donor Management Protocol on Lung Donation and Recipient Outcomes Pa O 2 /FI O 2 > 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:

44 Impact of Donor Management Protocol on Lung Donation and Recipient Outcomes Angel AJRCCM 2006;174:

45 Impact of Donor Management Protocol on Lung Donation and Recipient Outcomes Angel AJRCCM 2006;174:

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47 Early Donor Management Increases Retrieval Rate of Lung for TXP TimingWithin 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. Cath2 hours post consentOR Fem – A Line2 hours post consentOR EVLWIMeasuredNone PVPICalculatedNone BronchoscopyEarlyOR Trial Meds1 hour into managementOR TRIALNON - TRIAL Venkateswaran Ann Thorac Surg 2008; 85:

48 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 H 2 O Frequent Suctioning Volume recruitment by turning every 2 hours Active hemodynamic management Specific algorithms for CI > 2.5 L/min m 2 CVP and PCWP < 12 mm Hg MAP SVR 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: Management Points

49 Early Donor Management Increases Retrieval Rates of Lungs for TXP Respiratory function – deteriorated ↓ PaO 2 /FIO 2 ↑ EVLWI and PVPI PaO 2 /FIO 2 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 → PaO 2 / FIO 2 ratio deteriorated and EVLWI increased significantly NOT prevented by withdrawal of NE Management Outcomes Venkateswaran Ann Thorac Surg 2008; 85:

50 Early Donor Management Increases Retrieval Rate for Lungs for TXP Potential Lung Donors (182) Trial Lungs (120)Non Trial Lungs (244) T 3 (34) Placebo (28) MP(30)T 3 + 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:

51 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:

52 3.75 OPD Subtle Changes or Paradigm Shift? Joseph Kambe, M.D.

53 Improving What We Do. There are short term goals and long term goals. There are short term goals and long term goals Organs per Donor is a short term goal 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?

54 Donor 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 pressors. If you met the CVP goal and not use pressors. Does this mean you did something useful? Does this mean you did something useful? Or does it mean that the cardio/pulmonary axis was intrinsically good anyway? Or both? Or does it mean that the cardio/pulmonary axis was intrinsically good anyway? Or both?

55 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?

56 The Computer: CVP = 17 Would you diurese this patient?

57 CVP should estimate dLVP CVP will be falsely high. Positive pressure ventilation. PEEP. Pulmonary disease.

58 The Clinical Picture PEEP = 12 cm H 2 O. PEEP = 12 cm H 2 O. BP = 105/50 mmHg. BP = 105/50 mmHg. CI = 2.3 l/min/m 2. CI = 2.3 l/min/m 2.

59 Vasoactive 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 wall tension. HEART: diastolic root pressure - ventricular wall tension. Increase myocardial O 2 Consumption Increase myocardial O 2 Consumption All other organs are cardiac output dependent. All other organs are cardiac output dependent. There is a point where pressure comes at the expense of perfusion. There is a point where pressure comes at the expense of perfusion.

60 Vasoactive Drugs Dopamine: Dopamine: Highest incidence of arrhythmias, organ dysfunction, death. Highest incidence of arrhythmias, organ dysfunction, death. Causes norepinephrine release from the storage granules in the synapse. Causes norepinephrine release from the 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 not be used. Recent articles in CCM argue that it should not be used.

61 Norepinephine Activity depends on the number of alpha and beta receptors in the target organ. Activity depends on the number of alpha and beta receptors in the target organ. Under stimulation receptors are used up. Under stimulation receptors are used up. Only vasoactive drug we do not dose by weight. Only vasoactive drug we do not dose by weight. Why I know not. Why I know not.

62 Neosynephrine Pure alpha agonist. Pure alpha agonist. Causes peripheral vasoconstriction. Causes peripheral vasoconstriction. In neurogenic shock: there is peripheral vasoconstriction and cardiac depression. In neurogenic shock: there is peripheral vasoconstriction and cardiac depression. After-load increase = increased wall tension. After-load increase = increased wall tension.

63 Hormone Replacement N = 701 N = 701 Historical Control Non-Hormone Non-Hormone Replacement Replacement Hormone Hormone Replacement Replacement Age < 40 Age < opd 3.8 opd 4.2 opd 4.2 opd Age > 40 Age > opd 2.5 opd 3.1 opd 3.1 opd

64 So, Why Is this Controversial? Repeating this has been difficult/impossible. Repeating this has been difficult/impossible. Used T 3, most of us use T 4. Used T 3, most of us use T 4. These patients were all fed. These patients were all fed. The Company says T 4 is not stable in D 5 W. The Company says T 4 is not stable in D 5 W. The Company says T 4 is not stable as an infusion. The Company says T 4 is not stable as an infusion. As of now there is no data about these issues from the Company. As of now there is no data about these issues from the Company.

65 Conversion of T 4 T 4 is not the active hormone. T 4 is not the active hormone. T 4 must be converted to T 3 in the periphery. T 4 must be converted to T 3 in the 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 tone. Has an immediate action on vasomotor tone.

66 Actions of T 3

67 Intracellular T 3 Activity

68 T 3 Action in the Nucleus Increases RNA transcription/protein synthesis. Increases RNA transcription/protein 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 T 4. In illness, studies show giving T 4. Increases organ dysfunction and mortality. Increases organ dysfunction and mortality.

69 Furthermore How critical is the 6 – 8 hour delay in T 3 function in terms of repair (protein synthesis)? How critical is the 6 – 8 hour delay in T 3 function in terms of repair (protein synthesis)? Should we all be using T 3 ? Should we all be using T 3 ? 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?

70 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 same way. Education. Everyone needs to do it the same way. Does it matter? How are we going to find out? Does it matter? How are we going to find 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.

71 Plea for a National Database. Old medical axiom: WNL = we never looked. Old medical axiom: WNL = we never 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.

72 DONOR MANAGEMENT GOALS: Moving Toward a National Strategy NIL Get Connected Webinar October 13, 2009 Darren Malinoski, MD Assistant Professor of Surgery Director, Surgical Intensive Care Unit Chair, Organ Donor Council University of California, Irvine

73 BACKGROUND Donor Management Forum – August 2009 – Intensivists, Transplant Surgeons, OPO representatives, National Organizations Four predominant REQUESTS: 1.Increase Intensivist involvement 2.Increase the science of donor management 3.Tie donor management data to SRTR outcomes 4.Funding for research

74 PLAN FOR THIS SESSION Background on Donor Management Goals (DMGs) Region 10 Region 5 DMG initiative Survey Monkey results National DMG initiative

75 OTPD and DMGs

76 CONSENSUS Sodium < 155 MAP > 60 pH 7.25 – 7.5 CVP < 10 (or serum osmolality 285 – 295)

77 CONSENSUS 5 & 6 Pressors 1 or none (one pressor plus Vasopressin to treat DI is OK) pO 2 > 300 if on 100% O 2 ( or a P/F ratio > 3)

78 RESULTS FULL YEAR TOTAL CASES 264 Met Criteria = 34% 510 Did not meet criteria = 66%

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80 DONOR MANAGEMENT GOALS: The Region 5 DMG Project Part 1: Retrospective Part 2: Prospective

81 PROPOSED DMG’S for REGION 1. MAP CVP EF > 50% 4. 50% 4. 300 on PEEP = 5 7. Serum Sodium Urine output 1-3 cc/kg/hour 9. Glucose Pao2:Fio2 ratio >300 on PEEP = 5 7. Serum Sodium Urine output 1-3 cc/kg/hour 9. Glucose 10 Track hormone replacement usage Track hormone replacement usage

82 PART 1 - RETROSPECTIVE Universal template Universal template 40 SCD’s from each OPO 40 SCD’s from each OPO Retrospective collection of data regarding proposed DMG’s (prior to procurement) and organ disposition information Retrospective collection of data regarding proposed DMG’s (prior to procurement) and organ disposition information Statistical analyses: Statistical analyses: –80% DMG’s = goal met –>/= 4 OTPD = primary outcome measure –DMG-specific results –Other notable findings

83 DMG’S AND OTPD Mean # DMG’s with >/= 4 OTPD = 7.2 Mean # 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<0.001 When “goals met” When “goals met” –Mean OTPD = 4.4 –70% >/= 4 OTPD When “goals not met” When “goals not met” –Mean OTPD = 3.3 (t-test, p<0.001) –39% >/=4 OTPD (Pearson’s Chi-square, p /=4 OTPD (Pearson’s Chi-square, p<0.001)

84 Multivariate analysis - >/= 4 OTPD VariableOR 95% CI p value age <0.001 CVP EF > 50% <0.001 <0.001 Na Thyroid hormone Serum creatinine

85 Moving Forward – Current Project The Region agreed on 9 DMG’s to prospectively implement and track for 6 months. The Region agreed on 9 DMG’s to prospectively implement and track for 6 months. DMG’s will be measured at consent, hours later, and prior to going to OR DMG’s will be measured at consent, hours later, and prior to going to OR OTPD and graft outcome data will be analyzed OTPD and graft outcome data will be analyzed MAP > 60 MAP > 60 CVP 4-10 CVP 4-10 EF > 50% EF > 50% 300 P:F > 300 Sodium * Sodium * Glucose < 150 Glucose < 150 UOP 1-3 cc/kg/hr over preceding 4 hours UOP 1-3 cc/kg/hr over preceding 4 hours

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87 General Data Part 1 Part donors 320 donors 100% SCD 100% SCD DMG’s prior to OR DMG’s prior to OR Purely retrospective data Purely retrospective data DMG’s met = 8/10 DMG’s met = 8/10 Part 2 – July-Dec 2008 Part 2 – July-Dec donors 492 donors 380 (77%) SCD 380 (77%) SCD DMG’s at 3 time points DMG’s at 3 time points Prospective implementation Prospective implementation DMG’s met = 7/9 DMG’s met = 7/9 Graft Function Data Graft Function Data

88 Can we make a difference or is fate sealed before we start? DMG data (SCD’s only – n=255) <4 OTPD (n=132) >/=4 OTPD (n=123) p value DMG’s at consent (1) DMG’s at hrs (2) <0.001 DMG’s prior to OR (3) <0.001 Delta DMG Delta DMG Delta DMG

89 Multivariate analysis – Part 2 >/= 4 OTPD (n=376, 4 missing) VariableOR 95% CI p value Age <0.001 Terminal creatinine DMG 1 met DMG 2 met DMG 3 met Ejection fraction <0.001 Pao2:Fio

90 PART 2 CONCLUSIONS DMG’s are still associated with OTPD DMG’s are still associated with OTPD Changes in DMG’s over time are associated with OTPD Changes in DMG’s over time are associated with OTPD Pre-donor management is associated with outcomes Pre-donor management is associated with outcomes

91 SURVEY MONKEY RESULTS 41 OPO’s responding…

92 Does your OPO use DMGs?

93 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

94 If your region does not have uniform DMGs, would you be willing to do so?

95 Would your OPO be interested in participating in a National DMG Project?

96 How important is a National DMG initiative for advancing the science of donor care?

97 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

98 Future Directions Refine 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


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