A Priority Approach to Maximizing the Gift from Donation After Cardiac Death
Martin D. Jendrisak, MD, FACSMedical Director
Gift of Hope Organ and Tissue Donor Network
SRTR Data
Donation Stats as of July 15, 2011
National Organ Waiting List 111,827
Illinois Organ Waiting List 4,912
Indiana Organ Waiting List 1,513
Illinois Organ Waiting List By Organ
Kidney 4,111
Liver 495
Heart 141
Kidney/Pancreas 110
Pancreas 100
Lung 69
Intestine 10
Heart/Lung 1
DSA of 12 Million9 Transplant Centers180 Donor Hospitals
ReferralTransplant
AllocationConsent
Management Recovery
Transplant Partners
Catastrophic Neurologic Injury
Evaluation and Treatment in the Critical Care Setting
Clinical Trigger to donation Referral•Donation option is part of end of life care planning•Ensures this option is not denied to families•Timely notification of OPO is critical to process
Futility of Continuation of Care•Establish by health care providers
•Family understanding and acceptance
Death Determination
Death Determination
• By Neurologic Criteria (DBD)– Cessation of all brain activity (brain death)– Clinically established– Confirmatory testing when indicated
• By Circulatory – Respiratory Criteria (DCD) – Permanent absence of circulation and
respiration– Hospital DCD policy followed
IOM Committee Recommendation: 2006
DNDD – Donation after a neurological determination of death
DCDD – Donation after a circulatory determination of death
No
Brain Death DeterminationBrain Death Determination
Yes
ME/Coroner
Notification - Hospital
Consent for DonationConsent for Donation
ME/CoronerRelease - GOH
Yes No
1. Implement donor management protocols2. Donor Testing3. Organ Evaluation4. Organ Allocation5. Coordinate Surgical Recovery OR Access
1. Implement donor management protocols2. Donor Testing3. Organ Evaluation4. Organ Allocation5. Coordinate Surgical Recovery OR Access
Decision & Planning for Withdrawal of Care
Decision & Planning for Withdrawal of Care
Consent for DonationConsent for Donation
Yes No
Withdrawal of CareWithdrawal of Care
Death Pronouncement
Death Pronouncement
ME/Coroner
Notification - Hospital
Implement DCD Protocol: Time
Critical
Implement DCD Protocol: Time
Critical
ME/CoronerRelease - GOH
Protein S-100 Brain Injury Biomarker Study
Donor N s-100b p Value Injury-> Sample BD-> Sample
SCD 34 6.54 +/- 7.29 .0004 89.0 +/- 93.0 8.7 +/- 2.5
ECD 38 9.14 +/- 11.0 .0003 63.6 +/- 75.2 4.9 +/-3.0
DCD 30 4.18 +/- 6.40 .0243 81.2 +/- 66.5 N/A
DCD-A 30 1.37 +/- 1.83 ------- 136.3 +/- 114.9 N/A
Donor Management Requires a Collaborative Approach between OPO and
Donor Hospital Staff
Phases:•Identification•Referral & Initial Evaluation•Management of the Potential Donor•Brain Death and Consent•Donor Management•Special Interventions•Organ Specific Testing and Assessment
De-escalation of Care
Definition: Strategic reduction in the level of care in the setting of patient non-recovery
Examples: Withhold or reduce vasopressor support, transfusions, fluid and electrolyte resuscitation, pulmonary care, laboratory monitoring, etc.
Consequence on Donation: Renders organs not transplantable
Per CMS and Contractual Obligation: Hospitals and providers must provide adequate medical support to give families the option for organ donation.
Best Practice: (1) Early contact with GOH and (2) Provide full medical care until GOH determines non-donor status.
Donor Management - Goals
• Optimize Organ Viability
• Proper Assessment of Organ Quality
• Maximize Organ Utilization
• Optimize Outcomes of Transplantation
Consequences of the Pathophysiology of Brain Death
• Myocardial Dysfunction
• Hemodynamic Instability
• Neurogenic Pulmonary Edema
• Diabetes Insipidus
• Organ Dysfunction
Detrimental Physiological Effects of Brain Death
• Hemodynamic:• “Catecholamine storm”
• Cardiac dysfunction• Increase SVR• Capillary alveolar membrane damage
• Hormonal• Endocrinopathy
• Pituitary – ADH, TSH, ACTH
• Immunologic• Activation of inflammatory mediators
• IL-6, IL-10, ???
• Upregulated HLA Class II Expression
• Upregulated Expression of Adhesion Molecules
GIK Study
Cardiac Output Stroke Volume SVR
Case Age Sex Weight Pre- GIK Pre- GIK Pre- GIKOrgans
Transplanted
1 19 M 70kg 8.8 6.8 81 64 727 672 lu/li/k/p
2 45 M 78kg 4.5 4.6 52 65 1228 1236 li/k/p
3 33 F 139kg 4.6 7.2 38 61 1549 768 lu/li/k/p
4 17 M 64kg 2.5 9.2 28 74 li/k/p
5 47 M 72kg 4.0 12.9 46 91 740 1045 li/k
6 34 M 68kg 5.8 11.5 65 108 997 482 h/lu/li/k/p
SVR = Systemic Vascular Resistance; lu= lungs; li= liver, k= kidneys; p = pancreas; h = heart
Plexmark Study
IP - 10 MIG OPG
SCD 125.3+/-182.9 45.5+/-85.3 877.0+/985.5
ECD 275.9+/-519.7 32.2+/-48.9 801.6+/-662.4
DCD 8.7+/-11.6 2.0+/-4.5 280.4+/431.6
Cytokine Response to Steroids in DBD
Time IP - 10 MIG OPG
0 180.8+/-340.7 40.6+/-72.7 849.2+/-860.9
6 35.0+/-33.4 13.0+/23.9 434.3+/-382.9
12 20.6+/23.0 5.93+/-13.8 494.9+/-360.7
24 48.5+/-63.4 0 283.5+/-243.6
DCD PROCESS
• OPO evaluates donation candidacy• OPO coordinates organ procurement/allocation• Patient care team withdraws support, provides comfort
measures and pronounces death• Organ recovery initiated after death – time critical• Adherence to “Dead Donor Rule”
– Organ can be recovered only after death– Organ recovery process does not hasten death
DCD
• 90 minute time limit
• Warm ischemia limits transplant opportunity
– Kidneys – generally transplanted
– Liver, lungs, pancreas maybe transplanted if organ flush within 20 minutes and donor age<40
• DCD evaluation tool
Donation After Cardiac Death Tool
Criteria Assigned Points Point Score
0-30 131-50 251+ 3
BMI <25 1BMI 25 - 29 2BMI >30 3
Endotracheal Tube 3Tracheostomy 1
No Vasopressors/Inotropes 1Single Vasopressor/Inotropes 2Muliple Vasopressors/Inotropes 3
Rate >12 1Rate <12 3TV>200cc 1TV<200cc 3NIF>20 1NIF<20 3
No Spontaneous Respirations 9
02 Sat >90% 102 Sat 80-89% 202 Sat <79% 3
Oxygen Saturation After 10 minutes
Final Score
Patient Age
BMI Calculation*
Intubation
Vasopressors/Inotropes
Spontaneous Respirations after 10 minutes
Donation After Cardiac Death Tool
Final Score % Probability of Expiration In <60 minutes
% Probability of Expiration in <120 minutes
10 8 26
11 13 34
12 20 42
13 28 51
14 38 59
15 50 68
16 62 75
17 72 81
18 81 86
19 87 90
20 92 95
21 95 95
22 97 96
23 96 97
DCD TOOL LIMITATIONS
• 80% positive predictive value
• 20% donors missed
• Focused on uncertainty of the DCD process
• Clinician input may add complexity to the decision process
DCD PRACTICE CHANGE
• Started 3/1/2010• Omit DCD tool• Omit reliance on clinician prediction ability• Pursue all opportunities
– Potential for transplantable organs– Maximize the gift– Family driven
• Monitor practice through data analysis
Impact of the DCD Evaluation Tool on Organ Procurement
With Tool Without Tool ∆
Potential Cases 214 74
Exclusions 82 (38%) 16 (22%) 16%
Pursued Cases 132 (62%) 58 (78%)
Expired 117 (89%) 38 (66%)
DNE 15 (11%) 20 (34%) 23%
Missed Donors 15 (18%) 0 18%
Donation Patterns of DCD Expired Cases
With Tool Without Tool
Time to CPA
<90 min 117 38
<60 min 111 (95%) 38 (100%)
<30 min 98 (84%) 32 (84%)
<20 min 85(73%) 28(74%)
Positive Donors
Total 118 (89%) 29 (89%)
Extra-renal 39 (40%) 11 (40%)
Conclusions
• New DCD Practice Paradigm Maximizes The Gift– No missed donor opportunity– 20% increase in donation with transplantable
organs– Meet donor/family wishes 100% of time
• Demand On Donation Resources Acceptable– Identifies/excludes futile efforts (age>60)
Conclusions (Cont’d)
• Adds Clarity About DCD Process/Manages Expectations– 2 out of 3 attempts (on average),
transplantable organs are recovered– 3 out of 4 actual donors expire under 20
minutes to permit extra-renal organ recover/transplantation
– Clarity of message benefits family/staff