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