DMG Update UNOS Region 5 Collaborative December 12, 2012 Darren Malinoski, MD Megan Crutchfield, MPH...

DMG UpdateUNOS Region 5 Collaborative

December 12, 2012

Darren Malinoski, MDMegan Crutchfield, MPH

Section of Surgical Critical CarePortland VA Medical Center

Questions to Run On Do these data raise any questions or

research ideas?

How will you use this information moving forward?

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…

UNOS Region 5 DMG Web PortalLaunched in March – supported by Tii

Linked to DonorNet

Forced field entry

Generates reports

Recipient data added by Tii

Fields for study data

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

Regional Update – Phase 4 807 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

Phase 4 – organ utilization

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)

Web Portal Reports

Association between meeting the DMG Bundle and OTPD

OTPD WHEN DMGs NOT MET VS MET AT EACH TIME POINT

REFERRAL AUTHORIZATION 12-18 HOURS PRIOR TO OR

NOT MET

METNOT MET

METNOT MET

METNOT MET

MET

Phase 1 --- --- --- --- --- --- 3.34 4.35

Phase 2 --- --- 3.28 3.92 3.10 3.99 3.02 4.04

Phase 3 3.38 3.35 3.25 3.80 2.87 3.87 2.53 3.88

Phase 4 3.22 3.83 3.13 3.80 2.87 3.80 2.42 3.83

*(DCDDs and DNDDs used in phase 4), statistics not done yet

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

Association between Different Glucose thresholds and OTPD

OTPD WHEN GLUCOSE LEVEL MET VS NOT MET AT EACH TIME POINT

REFERRAL AUTHORIZATION 12-18 HOURS PRIOR TO OR

OTPD p OTPD p OTPD p OTPD p

< 150 3.41 0.989 3.45 0.236 3.47 0.450 3.47 0.200

> 150 3.41 3.35 3.42 3.39

< 180 3.47 0.162 3.45 0.449 3.44 0.737 3.48 0.015

> 180 3.34 3.39 3.47 3.29

< 200 3.46 0.102 3.46 0.410 3.47 0.259 3.47 0.006

> 200 3.32 3.40 3.38 3.21

Published/presented/ongoing research projects

HRSA Mild Hypothermia RCT HRSA-funded multi-OPO randomized

controlled trial Intervention: Mild Hypothermia (34-35C)

vs. Normothermia (36.5-37.5) for > 12 hrs prior to organ recovery

Main outcome measures: DGF and SGF Inclusion criteria: hemodynamically

stable abdominal organ donors

HRSA Mild Hypothermia RCT Enrolled 123 Donors since March 15th

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

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

≤ 4 5 6 7 8 ≥ 9Number of DMGs achieved

0

1

2

3

4

5

DMG/Variable

OR(>4

OTPD) 95% CI p valueContinuous Variables

Age (years) 0.944 0.923 – 0.966 < 0.001

Creatinine (mg/dL) 0.636 0.409 – 0.987 0.044

Categorical Variables

Thyroid Hormone use 1.969 1.082 – 3.582 0.026

CVP 4 – 10 mmHg 1.897 1.021 – 3.527 0.043

EF > 50% 3.988 2.095 – 7.592 < 0.001

P:F > 300 on PEEP 5 4.591 2.478 – 8.506 < 0.001

Na 135 – 160 mEq/L 3.352 1.141 – 9.851 0.028

“Goals met” 4.394 2.497 – 7.732 < 0.001

Variable OR 95% CI p

Age (per year)1.02

1.01-1.03

0.003

Creatinine prior to recovery (per mg/dL) 1.4 1.1-1.6

0.001

ECD0.9 0.5-1.5

0.664

Cold ischemia time (per hour)

1.03 1.01-1.05

0.011

DMGs met at consent 0.5 0.3-0.9 0.019

- In press with the American Journal of Transplantation

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

[all donors included] Not on State Registry

(n=489)

On State Registry

(n=144)

p value

DMGs met at referral 9% 9% 0.846

DMGs met at consent 22% 20% 0.655

DMGs met 12-18 hours 48% 52% 0.334

DMGs met prior to OR 58% 69% 0.019

OTPD 3.23 + 1.8 3.51 + 1.9 0.104

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

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.

Variables Associated with Liver Graft Transplantation Lower Age Lower BMI Male Gender SCD status (vs. ECD) Higher MAP Lower CVP Higher Ejection Fraction Higher PaO2:FiO2 Lower Glucose Vasopressin use

Variables Associated with Liver Graft Discard

From 873 Procured livers… 730 Livers Transplanted, 143 Livers Discarded (16%)

Variables Associated with Liver Graft Discard Older Age Higher BMI Female Gender ECD status (vs. SCD) Higher CVP Lower Urine Output Lower PaO2:FiO2 Lower thyroid hormone dosages

Variables Associated with Liver Graft Survival

730 Livers Transplanted• 694 (95%) survival after 74±73 days

Variable Graft Survival vs. Failure

Age (years) 38 vs. 44

BMI (kg/m2) 26 vs. 30

SCD 96% vs. 91%

Male Gender 96% vs. 94%

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

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

Questions to Run On Do these data raise any questions or

research ideas?

How will you use this information moving forward?