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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?
