Donor Management Goals Research Articles

Survey of U.S. Organ Procurement Organizations Regarding Pediatric Organ Donor Management.

To describe the current practice of pediatric organ donor management in the United States for donors declared dead based upon neurologic criteria. The study directs particular attention to how pediatric donors are defined, the use of donor management guidelines, the use of donor management goals, and the involvement of pediatric critical care or transplantation expertise. Cross-sectional observational study using a web-based survey and follow-up telephone interview with respondents from U.S. organ procurement organizations. The study also incorporated organ procurement organization-specific data on organ yield for the 4-year period (2010-2013) preceding the study. The 58 U.S. organ procurement organizations. Respondents chosen by each organ procurement organization. None. All 58 U.S. organ procurement organizations participated in the study. Fifty-two respondents (90%) indicated that their organ procurement organization distinguished pediatric from adult donors resulting in 28 unique pediatric definitions. Thirty-nine organ procurement organizations utilized some form of written pediatric management guidelines, and 27 (47%) maintained pediatric donor management goals; compliance was infrequently monitored for both guidelines (28%) and goals (33%). A pediatric intensivist was always or usually involved in pediatric donor management at 47 organ procurement organizations (81%); transplant/organ recovery surgeons were always or usually involved at 12 organ procurement organizations (21%). There was an increase in the number of organs transplanted per donor among donors 11-17 years old for organ procurement organizations that used donor management goals for the duration of the period studied (p < 0.01). There was also an increase in the ratio of observed/expected organs transplanted among donors of 0-10 years old for organ procurement organizations that always or usually consulted a transplant/organ recovery surgeon (p = 0.02) although this did not reach our threshold for statistical significance.. There is little consensus among organ procurement organizations regarding the definition of "pediatric" during organ donor management. Most organ procurement organizations employ written pediatric guidelines and use pediatric intensive care physicians for assistance in managing these donors. There is a positive association between the use of donor management goals and organ yield among pediatric donors in the 11- to 17-year age group.

The development and current status of Intensive Care Unit management of prospective organ donors

Introduction:Despite continuous advances in transplant medicine, there is a persistent worldwide shortage of organs available for donation. There is a growing body of research that supports that optimal management of deceased organ donors in Intensive Care Unit can substantially increase the availability of organs for transplant and improve outcomes in transplant recipients.Methods:A systematic literature review was performed, comprising a comprehensive search of the PubMed database for relevant terms, as well as individual assessment of references included in large original investigations, and comprehensive society guidelines.Results:In addition to overall adherence to catastrophic brain injury guidelines, optimization of physiologic state in accordance with established donor management goals (DMGs), and establishment of system-wide processes for ensuring early referral to organ procurement organizations (OPOs), several specific critical care management strategies have been associated with improved rates and outcomes of renal transplantation from deceased donors. These include vasoactive medication selection, maintenance of euvolemia, avoidance of hydroxyethyl starch, glycemic control, targeted temperature management, and blood transfusions if indicated.Conclusions:Management of deceased organ donors should focus first on maintaining adequate perfusion to all organ systems through adherence to standard critical care guidelines, early referral to OPOs, and family support. Furthermore, several specific DMGs and strategies have been recently shown to improve both the rates and outcomes of organ transplantation.

P.7.f.008 How do psychiatrists recommend children and adolescents to use the smartphones

Brain dead organ donors have altered central hemodynamic performance, impaired hormone physiology, exaggerated systemic inflammatory response, end-organ microcirculatory dysfunction, and tissue hypoxia. A new treatment, direct peritoneal resuscitation (DPR), stabilizes vital organ blood flow after conventionally resuscitated shock to improve these derangements.A prospective case-control study of adjunctive DPR compared 26 experimental patients (brain dead organ donors) to 52 controls (protocolized conventionally resuscitated donors). Actual organ procurement rates were compared with the Scientific Registry of Transplant Recipient predicted organ yield per patient. Achievement of donor management goals and effective hepatic blood flow were recorded.Fourteen of 26 (53.8%) patients treated with DPR achieved all donor management goals compared with 17 of 52 (32.7%) patients treated with conventionally resuscitated (odds ratio = 2.4; 95% CI, 0.92–6.3; p = 0.06). Patients treated with DPR were more than 2 times as likely to achieve final pO2 >100 on 40% FiO2 compared with controls (odds ratio = 2.8; 95% CI, 1–7.69; p = 0.03). Also, DPR-treated patients required less IV crystalloid during the first 12 hours of management (DPR: 3,167 ± 1,893 mL vs 4,154 ± 2,100 mL; p = 0.046) and required less vasopressor agents at 12 hours post resuscitation (odds ratio = 7.7; 95% CI, 0.82–42; p = 0.02). Direct peritoneal resuscitation patients had enhanced effective hepatic blood flow and significantly higher organs transplanted per donor rates compared with controls (3.7 ± 1.7 vs 3.1 ± 1.3; p = 0.024).Direct peritoneal resuscitation reduced IV fluid requirement and IV pressor use as well as increased hepatic blood flow and organs transplanted per donor. Direct peritoneal resuscitation studies show it to be a safe, effective method to augment organ donor resuscitation and additional large-scale trials should be conducted to validate these findings.

Addition of Direct Peritoneal Lavage to Human Cadaver Organ Donor Resuscitation Improves Organ Procurement

Brain dead organ donors have altered central hemodynamic performance, impaired hormone physiology, exaggerated systemic inflammatory response, end-organ microcirculatory dysfunction, and tissue hypoxia. A new treatment, direct peritoneal resuscitation (DPR), stabilizes vital organ blood flow after conventionally resuscitated shock to improve these derangements. A prospective case-control study of adjunctive DPR compared 26 experimental patients (brain dead organ donors) to 52 controls (protocolized conventionally resuscitated donors). Actual organ procurement rates were compared with the Scientific Registry of Transplant Recipient predicted organ yield per patient. Achievement of donor management goals and effective hepatic blood flow were recorded. Fourteen of 26 (53.8%) patients treated with DPR achieved all donor management goals compared with 17 of 52 (32.7%) patients treated with conventionally resuscitated (odds ratio = 2.4; 95% CI, 0.92-6.3; p = 0.06). Patients treated with DPR were more than 2 times as likely to achieve final pO2 >100 on 40% FiO2 compared with controls (odds ratio = 2.8; 95% CI, 1-7.69; p = 0.03). Also, DPR-treated patients required less IV crystalloid during the first 12 hours of management (DPR: 3,167 ± 1,893 mL vs 4,154 ± 2,100 mL; p = 0.046) and required less vasopressor agents at 12 hours post resuscitation (odds ratio = 7.7; 95% CI, 0.82-42; p = 0.02). Direct peritoneal resuscitation patients had enhanced effective hepatic blood flow and significantly higher organs transplanted per donor rates compared with controls (3.7 ± 1.7 vs 3.1 ± 1.3; p = 0.024). Direct peritoneal resuscitation reduced IV fluid requirement and IV pressor use as well as increased hepatic blood flow and organs transplanted per donor. Direct peritoneal resuscitation studies show it to be a safe, effective method to augment organ donor resuscitation and additional large-scale trials should be conducted to validate these findings.

The impact of meeting donor management goals on the number of organs transplanted per expanded criteria donor: a prospective study from the UNOS Region 5 Donor Management Goals Workgroup.

The shortage of organs available for transplant has led to the use of expanded criteria donors (ECDs) to extend the donor pool. These donors are older and have more comorbidities and efforts to optimize the quality of their organs are needed. To determine the impact of meeting a standardized set of critical care end points, or donor management goals (DMGs), on the number of organs transplanted per donor in ECDs. Prospective interventional study from February 2010 to July 2013 of all ECDs managed by the 8 organ procurement organizations in the southwestern United States (United Network for Organ Sharing Region 5). Implementation of 9 DMGs as a checklist to guide the management of every ECD. The DMGs represented normal cardiovascular, pulmonary, renal, and endocrine end points. Meeting the DMG bundle was defined a priori as achieving any 7 of the 9 end points and was recorded at the time of referral to the organ procurement organization, at the time of authorization for donation, 12 to 18 hours later, and prior to organ recovery. The primary outcome measure was 3 or more organs transplanted per donor and binary logistic regression was used to identify independent predictors with P < .05. There were 671 ECDs with a mean (SD) number of 2.1 (1.3) organs transplanted per donor. Ten percent of the ECDs had met the DMG bundle at referral, 15% at the time of authorization, 33% at 12 to 18 hours, and 45% prior to recovery. Forty-three percent had 3 or more organs transplanted per donor. Independent predictors of 3 or more organs transplanted per donor were older age (odds ratio [OR] = 0.95 per year [95% CI, 0.93-0.97]), increased creatinine level (OR = 0.73 per mg/dL [95% CI, 0.63-0.85]), DMGs met prior to organ recovery (OR = 1.90 [95% CI, 1.35-2.68]), and a change in the number of DMGs achieved from referral to organ recovery (OR = 1.11 per additional DMG [95% CI, 1.00-1.23]). Meeting DMGs prior to organ recovery with ECDs is associated with achieving 3 or more organs transplanted per donor. An increase in the number of critical care end points achieved throughout the care of a potential donor by both donor hospital and organ procurement organization is also associated with an increase in organ yield.

The Impact of Meeting Donor Management Goals on the Development of Delayed Graft Function in Kidney Transplant Recipients

Many organ procurement organizations (OPOs) utilize preset critical care endpoints as donor management goals (DMGs) in order to standardize care and improve outcomes. The objective of this study was to determine the impact of meeting DMGs on delayed graft function (DGF) in renal transplant recipients. All eight OPOs of the United Network for Organ Sharing Region 5 prospectively implemented nine DMGs in every donor after neurologic determination of death (DNDD). "DMGs met" was defined a priori as achieving any seven of the nine DMGs and this was recorded at the time of consent for donation to reflect donor hospital ICU management, 12-18 h later, and prior to organ recovery. Multivariable analyses were performed to identify independent predictors of DGF (dialysis in the first week after transplantation) with a p<0.05. A total of 722 transplanted kidneys from 492 DNDDs were included. A total of 28% developed DGF. DMGs were met at consent in 14%, 12-18 h in 32% and prior to recovery in 38%. DGF was less common when DMGs were met at consent (17% vs. 30%, p=0.007). Independent predictors of DGF were age, Cr and cold ischemia time, while meeting DMGs at consent was significantly protective. The management of potential organ donors prior to consent affects outcomes and should remain a priority in the intensive care unit.

Deceased Organ Donor Research: The Last Research Frontier?

Deceased Organ Donor Research: The Last Research Frontier?

The impact of meeting donor management goals on the number of organs transplanted per donor

Many organ procurement organizations have implemented critical care end points as donor management goals in efforts to increase organs transplanted per donor after neurologic determination of death. Although retrospective studies have demonstrated an association between meeting donor management goals and organ yield, prospective studies are lacking. In June 2008, nine donor management goals were prospectively implemented as a checklist and every donor after neurologic determination of death was managed to meet them. The donor management goals represented normal cardiovascular, pulmonary, renal, and endocrine end points. Data were collected for 7 months. Donor management goals "met" was defined a priori as achieving any seven of the nine donor management goals, and this was recorded at the time of consent, 12-18 hrs later, and prior to organ recovery. The primary outcome measure was ≥4 organs transplanted per donor, and binary logistic regression was used to identify independent predictors of this outcome with a p<.05. All eight organ procurement organizations in the five Southwestern United States (United Network for Organ Sharing Region 5). All standard criteria donors after neurologic determination of deaths. Prospective implementation of a donor management goal checklist. There were 380 standard criteria donors with 3.6±1.7 organs transplanted per donor. Fifteen percent had donor management goals met at the time of consent, 33% at 12-18 hrs, and 38% prior to organ recovery. Forty-eight percent had ≥4 organs transplanted per donor. Donors with ≥4 organs transplanted per donor had significantly more individual donor management goals met at all three time points. Independent predictors of ≥4 organs transplanted per donor were age (odds ratio=0.95 per year), final creatinine (odds ratio=0.75 per 1-unit increase), donor management goals "met" at consent (odds ratio=2.03), donor management goals "met" prior to organ recovery (odds ratio=2.34), and a change in the number of donor management goals achieved from consent to 12-18 hrs later (odds ratio=1.13 per additional donor management goal). Meeting donor management goals prior to consent and prior to organ recovery were both associated with achieving ≥4 organs transplanted per donor. However, only 15% of donors have donor management goals met at the time of consent. The donor hospital management of patients with catastrophic brain injuries, before the intent to donate organs is known, affects outcomes and should remain a priority in the intensive care unit.

Impact of Catastrophic Brain Injury Guidelines on Donor Management Goals at a Level I Trauma Center

BackgroundAn organ procurement organization (OPO) and a level I trauma center developed catastrophic brain injury guidelines (CBIGs) to assist in the care of severely brain-injured adult patients before brain death. The CBIGs provided a set of clinical guidelines to maintain patient stability and optimize opportunity for organ donation. ObjectiveThe aim of this study was to determine if the use of the CBIGs affected the OPO's ability to achieve donor management goals (DMGs) before organ recovery. MethodsWe conducted a retrospective analysis comparing the number of DMGs met in the hospital's donors before and after the CBIGs were used. The analysis included 133 cases; 67 donors in the pre-CBIG data and 66 donors in the post-CBIG review. Donor management goals measured included: systolic blood pressure >100 mm Hg; 1 pressor ≤10 μg/kg/min; urine output 1–2 mL/kg/h; pO2 >100 mm Hg; Na <160 meq/L; pH within normal limits (7.35–7.45); temperature 36.5–37.5°C; arterial line in place and central line in place with monitor. ResultsAfter the introduction of the CBIGs, 78% of DMGs were met more often, with 1 goal (Na) remaining equivalent and 2 goals (pO2 and pH) met less often. Increase in achievement of individual DMGs ranged from 4% to 33%. The pre-CBIG cases averaged 2.90 missed goals per donor compared with an average of 1.79 in the post-CBIG data. Only 5 pre-CBIG donors (7%) achieved all of the DMGs. That figure rose to 12 donors (18%) in the post-CBIG data. ConclusionsWhile other factors may have contributed to our results, we think that there is a positive relationship between the CBIGs and the increase in meeting most DMGs. As we refine our donor management, we will focus on the factors we met less successfully. Ultimately, the use of the CBIGs before brain death led to more stable donors, maximizing transplantable organs.

The Reward is Worth the Wait: A Prospective Analysis of 100 Consecutive Organ Donors

Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor preprocurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.

Achieving Donor Management Goals Before Deceased Donor Procurement Is Associated With More Organs Transplanted Per Donor

There is a national shortage of organs available for transplantation. Implementation of preset donor management goals (DMGs) to improve outcomes is recommended, but uniform practices and data are lacking. We hypothesized that meeting DMGs before organ procurement would result in more organs transplanted per donor (OTPD). The eight organ procurement organization in United Network for Organ Sharing Region 5 selected 10 critical care end points as DMGs. Each organ procurement organization submitted retrospective data from 40 standard criteria donors. "DMGs met" was defined as achieving any eight DMGs before procurement. The primary outcome was ≥4 OTPD. Binary logistic regression was used to determine independent predictors of ≥4 OTPD with a p<0.05. Three hundred twenty standard criteria donors had 3.6±1.6 OTPD. Donors with DMGs met had more OTPD (4.4 vs. 3.3, p<0.001) and were more likely to have ≥4 OTPD (70% vs. 39%, p<0.001). Independent predictors of ≥4 OTPD were age (odds ratio [OR]=0.94), serum creatinine (OR=0.65), thyroid hormone use (OR=2.0), "DMGs met" (OR=4.4), and achieving the following individual DMGs: central venous pressure 4 mm Hg to 10 mm Hg (OR=1.9), ejection fraction>50% (OR=4.0), Pao2:FIO2>300 (OR=4.6), and serum sodium 135 to 160 mEq/L (OR=3.4). Meeting DMGs before procurement resulted in more OTPD. Donor factors and critical care end points are independent predictors of organ yield. Prospective studies are needed to determine the true impact of each DMG on the number and function of transplanted organs.

Optimization of Donor Management Goals Yields Increased Organ Use

Multiple strategies have been used in an effort to increase the pool of organs for transplantation. Standardizing donor management has produced promising results. Donor management goals (DMGs) are now being used as end points of intensive care unit care during the prerecovery phase but no prospective results have been reported. Data from the United Network for Organ Sharing Region 11 were collected for successful achievement of eight common donor management goals (mean airway pressure [MAP], central venous pressure [CVP], pH, PaO2, sodium, glucose, single pressor use, and urine output) before organ recovery. Two time periods were studied with different panels of DMGs. The analysis identified the success rate of transplantation. Goals were stratified by their statistical correlation with the number of organs transplanted per donor (OTPD) in an effort to identify the most important parameter(s). Eight hundred five organ donors were studied with 2685 organs transplanted. DMGs were assessed through two phases of the study. Achieving DMGs rose from 18 to 66 per cent associated with significant improvement in OTPD (range, 2.96 to 3.45). The success of transplantation was primarily associated with limitations in vasopressor use and PaO2. Tight glucose control did affect the rate of pancreatic transplants. Thoracic organs were the most sensitive to DMGs with a 10- to 15-fold increase in lung transplantation when PaO2 rose above 100 mmHg. MAP, CVP, pH, sodium, and urine output had little effect on transplantation. Standardization of end points of donor management was associated with increased rates of transplantation. Surprisingly, not all standard goals are necessary for optimal organ use. The most significant parameters were the low use of vasopressor agents and oxygenation. Donor management strategies should strive to optimize these goals.

Attaining Specific Donor Management Goals Increases Number of Organs Transplanted per Donor: A Quality Improvement Project

Most organ procurement organization professionals and transplant surgeons intuitively know that meeting donor management goals improves organ allocation and transplant outcomes. In this era of evidence-based medicine, it is important to know whether the data support this assumption. All 6 organ procurement organizations in the United Network for Organ Sharing's region 10 agreed on 6 specific donor management goals. The organ procurement organizations then compared the number of organs transplanted per donor when goals were met with the number when goals were not met. Results were broken down by donor type: standard-criteria donation, expanded-criteria donation, and donation after cardiac death. For all 6 organ procurement organizations combined, the data for all of 2008 show a substantial and statistically significant improvement in number of organs transplanted per donor for standard criteria donation and total donors when goals are met, with a smaller degree of improvement (although not statistically significant) in the number of organs transplanted per donor for expanded-criteria donation and donation after cardiac death when goals are met.

Attaining specific donor management goals increases number of organs transplanted per donor: a quality improvement project

Most organ procurement organization professionals and transplant surgeons intuitively know that meeting donor management goals improves organ allocation and transplant outcomes. In this era of evidence-based medicine, it is important to know whether the data support this assumption. All 6 organ procurement organizations in the United Network for Organ Sharing's region 10 agreed on 6 specific donor management goals. The organ procurement organizations then compared the number of organs transplanted per donor when goals were met with the number when goals were not met. Results were broken down by donor type: standard-criteria donation, expanded-criteria donation, and donation after cardiac death. For all 6 organ procurement organizations combined, the data for all of 2008 show a substantial and statistically significant improvement in number of organs transplanted per donor for standard criteria donation and total donors when goals are met, with a smaller degree of improvement (although not statistically significant) in the number of organs transplanted per donor for expanded-criteria donation and donation after cardiac death when goals are met.