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DMG Update UNOS Region 5 Collaborative

DMG Update UNOS Region 5 Collaborative . December 12, 2012 Darren Malinoski, MD Megan Crutchfield, MPH Section of Surgical Critical Care Portland VA Medical Center. Questions to Run On. Do these data raise any questions or research ideas? How will you use this information moving forward?.

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DMG Update UNOS Region 5 Collaborative

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  1. DMG UpdateUNOS Region 5 Collaborative December 12, 2012 Darren Malinoski, MD Megan Crutchfield, MPH Section of Surgical Critical Care Portland VA Medical Center

  2. Questions to Run On • Do these data raise any questions or research ideas? • How will you use this information moving forward?

  3. 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…

  4. 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

  5. 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

  6. 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

  7. Phase 4 – organ utilization

  8. 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)

  9. Web Portal Reports

  10. Association between meeting the DMG Bundle and OTPD *(DCDDs and DNDDs used in phase 4), statistics not done yet

  11. 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

  12. Association between Different Glucose thresholds and OTPD

  13. Published/presented/ongoing research projects

  14. 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

  15. 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

  16. 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

  17. - In press with the American Journal of Transplantation

  18. 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

  19. 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

  20. 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.

  21. 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

  22. Variables Associated with Liver Graft Discard • From 873 Procured livers… • 730 Livers Transplanted, • 143 Livers Discarded (16%)

  23. 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

  24. Variables Associated with Liver Graft Survival • 730 Livers Transplanted • 694 (95%) survival after 74±73 days

  25. 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

  26. 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

  27. Questions to Run On • Do these data raise any questions or research ideas? • How will you use this information moving forward?

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