Download Donor Management Goals - Organ Donation Alliance

Management of the
Potential Organ Donor
Kenneth E. Wood, D.O.
Professor of Medicine and Anesthesiology
Senior Director of Medical Affairs
Director of Critical Care Medicine and Respiratory Care
The Trauma and Life Support Center
University of Wisconsin Hospital and Clinics
Disclaimer
No Financial Support
Slides Available by Request
[email protected]
Maximal Utilization and Optimal
Management of Potential Organ Donors
• Surveillance to identify patients with severe
neurologic injury likely to progress to brain death
• Standardized method for brain death declaration
• Uniform request for consent
• Optimal medical management of donor
Optimal Medical Management of the
Potential Organ Donor
• Continued intensity of support
• Focus shift from cerebral protective strategies to
optimizing donor organs for transplantation
• Simultaneous critical care to organs of multiple
patients
• Critical period
• Facilitates donor somatic survival
• Maintains organs to be procured best
condition
• Donor management impact recipient function
Role of Clinical Care Team in Donation
• Donor Medical Management = Critical Care
Management
• Integrative multi-disciplinary collaborative
approach between OPO and Clinical Care Team
•Intensivists
•Pulmonary Consultants
•Cardiac Consultants
•Nursing
•Respiratory
•Hemodynamics
•Ventilatory Management
•Echocardiography
•Diagnostic Procedures
• Donor Management Team/Defined Champions
• Donor Family Support
Cardiac Transplant Continuum
Mechanism
•Catecholamine
Hypothesis
NEURO
INJURY
Approach
•Standard
•Autonomic Surge
•Endocrinopathy
•MVO2 supply
demand imbalance
• Coronary perfusion
•Aerobic  Anerobic
BRAIN
DEATH
•Pretreatment ?
•Sympathetic antagonists
•Calcium blockers
•Cardiac sympathectomy
DONOR
•Fluids
•Immunomodulators
catecholamines
•Vasopressin
•Thyroid hormone
•Steroids
•Insulin
Improvement of Donor Myocardial Function After
Treatment of Autonomic Surge During Brain Death
•Defined by Systolic BP > 200 mmkg •AS less with head injury
and tachycardia > 140 beats/min.
•Treated with esmolol, urapidil
•Observed in 63%
or nicardipine
•Duration 1.2 hours (30 min-6hr)
•Followed by  BP which never
occurred when AS absent
•Treatment independently
associated with EF > 50%
Audibert Transplantation 2006;82:1031-1036
Complications of Brain Death and Impact on
Organ Retrieval
“…hypothesized that brain death related
complications would have no effect on the
number of organs donated if an aggressive
donor management protocol was in place.”
•Vasopressor requirement 97.1% •Cardiac ischemia 30.4%
•Coagulopathy 55.1%
•Lactic acidosis 24.6%
•Thrombocytopenia 53.6%
•Renal failure 20.3%
•Diabetes Insipidus 46.4%
•ARDS 13%
Salim Am Surgeon 2006;72:377-381
Aggressive Donor Management and
Organ Donor Shortage
Salim 2006;61:429-435
Transforming Unacceptable Donors
Potential Multi-organ Donors (150)
Acceptable 65% (98)
Unacceptable 35% (52)
•
•
•
•
•
•
•
•
•
•
40% (21) MAP < 55 (mean 47 mmHg)
despite inotropic support
19% (10) CVP > 15 (mean 18 mmHg)
4% (2) inotropes > 20 (mean 25 ug/Kg/min)
25% (13) PCWP > 15 (mean 20 mmHg)
12% (6) LVSWI < 15 (mean 12.8 gm)
Outcomes
Optimum Management
•
•
•
•
•
Invasive monitoring
Bolus steroids (15mg/Kg/MP)
Insulin/glucose
Argine vasopressin 1U bolus
and 1.5 U/hr
Tri-iodothyronine 4 ug bolus
and 3 ug/hr
MAP > 60 mmHg
CVP < 12 mmHg
PCWP < 12 mmHg
LVSWI > 15 gm
Inotropes < 5 ug/Kg/mm
•
•
•
44/52 “unacceptable” donors
yielded transplantable organs
84% alive (13-48 months)
92% of initially unacceptable
organs were capable of
functional resuscitation
Wheeldon J Heart Lung Txp 1995; 14:734-742
Donor Management Trial
Hormonal Therapy Randomization
T3 0.8 ug/Kg
Bolus
Followed by
0.113
μg/Kg/hr
T3 And Methylprednisolone
Methylprednisolone
1000 mg
Bolus
Placebo
Venkateswaran Eur Heart J 2009
Hemodynamic Effects ofMarginal
Adjunctive
Hormonal•MAP
Therapy
< 70 mmHg
Functional
•CVP < 12 mmHg
•PCWP < 14 mm Hg Brain Stem Death (80) with
• Trauma•CVP
24%or PCWP > 14 mmHg
•CI > 2.5 L/min
• Vascular event/tumor 64%
and
•Minimal vasoactive • Hypoxia/Infection 13%
support
•CI < 2.4 L/min
Management
•No
gross LVH or palpable
Brain
Death
OR
Consent
Management
HRT
Retrieval
Coning
CAD on inspection
•Dopamine > 5 μg/Kg/min
or
10.7 hrs
2 hrs
1 hr
5.9 hrs
•Norepi > 0.06 μg/Kg/min
12.7 hrs
or
19.6 hrs
6.9 hrs
•Epi > 0.03 Venkateswaran
μg/Kg/minEur Heart J 2009
Hemodynamic Parameters for Entire Trial Cohort
Venkateswaran Eur Heart J 2009
Cardiac Index and Treatment
Venkateswaran Eur Heart J 2009
Donor Heart Function and Thyroid Function
•
•
•
•
58% Low free T3 or T4
18% co-existent low TSH
Initial CI no different with low T3 or T4
CI ↑ regardless of initial T3 or T4 or T3 Tx
Venkateswaran Eur Heart J 2009
Cardiac Index and Pre-Tx Thyroid
Venkateswaran Eur Heart J 2009
Donor Heart Function and
Norepinephrine
• Association between NE withdrawal and cardiac
functional improvement
• 60% (48/80) initially receiving NE
• Significantly lower LVSWI (43.5 vs 36.6)
• Vasopressin introduced 60/80 → NE withdrawn in
26/48 or reduced to 0.06 μg/Kg/min
CI
SVR
Norepi
Vasopressin
3.18
1190
3.72
964
Venkateswaran Eur Heart J 2009
Hemodynamic Effects of Adjunctive
Hormone Therapy
Trial Donors (80)
50% Non-Marginal at
Initial Assess (40)
35% Unsuitable at End
Assessment (14)
•CAD (5)
•RV Dysfunction (5)
•LV Dysfunction (4)
50% Marginal at Initial
Assess (40)
65% Suitable
at End
Assessment
(26)
35% Suitable
at End
Assessment
(14)
58% Retrieved
for TXP (15)
71% Retrieved
for TXP (10)
65% Unsuitable at End
Assessment (26)
•CAD (15)
•RV Dysfunction (6)
•LV Dysfunction (5)
Total Suitable at End Assessment (40)
63% Hearts Txp (25)
Venkateswaran Eur Heart J 2009
37% Non-Txp (15)
•No Recipient (10)
•Age > 60 (3)
•Poor Donor Txp (2)
Donor Management
“Active donor management improves
circulatory function and has the
capacity to increase the yield of
suitable hearts from the existing pool
of potential donors. Neither T3 nor MP,
alone or in combination, appears
fundamental to this improvement.”
Venkateswaran Eur Heart J 2009
Donor Management
“Our study demonstrates that not only may donor
circulatory status be improved by active management
but also there is the potential to increase the yield of
transplantable hearts if decisions on organ
acceptance are deferred until a period of resuscitation
and assessment is complete. Active donor
management with PAFC monitoring is the
cornerstone of this objective but this has implications
for planning donor retrieval services. The simple
introduction of hormone therapy is not a substitute
for the detailed haemodynamic assessment and
management of the potential heart donor.”
Venkateswaran Eur Heart J 2009
Role of Brain Death in Donor Lung Injury
Neurogenic Pulmonary Edema
• “Blast Injury Theory” → Hemodynamic mechanism
• Sympathetic surge
Left
↑ SVR ↓CO ↑LAP
Right ↑ Pvc ↑ VR ↑PAP ↑Pul Volume
• Transient massive ↑ hydrostatic pressure with
structural damage to capillary endothelium
• Sympathetic alteration of capillary permeability
Inflammatory Response
• Cytokines → TNF IL-1 activate endothelial cells to express
adhesion molecules and mediate production of IL-8 →
neutrophil activator → bind to endothelial cells → migrate to
interstitium/alveolar spaces → release ROS and proteolytic
enzymes
Alvonitis Trasnaplantation 2003; 75:1928-1933
Potential Lung Donor
Ideal Lungs
•
•
•
•
•
•
PaO2/FiO2 > 300
PEEP = 5cmH2O
Clear chest x-ray
Age < 55
Tobacco < 20 pk/yr
Absence of trauma,
surgery, aspiration,
secretions,
malignancy
purulent secretions
“Marginal” Lungs
Unacceptable Lungs
Baseline
Status
Acquired
reversible
Atelactasis
Alveolar
Flooding
Aspiration
Impact of Donor Management Protocol on Lung
Donation and Recipient Outcomes
Education
• Transplant Pulmonologists and OPO staff training
sessions on Donor selection and management
• Emphasis upon every donor as a lung donor
• Request and consent should be attempted for
every donor
• Education regarding donor management strategies
Angel AJRCCM 2006;174:710-716
Impact of Donor Management Protocol on
Lung Donation and Recipient Outcomes
Active Management
• Recruitment Maneuvers
• Pressure control ventilation 25 cm H2O and PEEP 15 cm
H2O for 2 hours
• Switch to conventional volume control mode with TV 10
ml/kg and PEEP 5 cm H2O
• Fluid balance
• Minimized use of crystalloids
• Diuretics to maintain neutral or negative balance
• Aspiration risk
• Elevated head of bed to 300
• Inflate ET balloon to 25 cm H2O
• Bronchosopy with BAL to eval CXR area of infiltrate
Angel AJRCCM 2006;174:710-716
Impact of Donor Management Protocol on Lung
Donation and Recipient Outcomes
Absolute
• PaO2/FIO2 > 300
• No infiltrates
• No copious purulent
secretions
• No bronchoscopically
demonstrated aspiration
•Ideal
•All absolute criteria
•No extended criteria
•Extended
•All absolute criteria
•One or more extended criteria
•Poor
•Did not satisfy ALL absolute criteria
Extended
• Age > 55 years
• Pack years > 20
• History of pulmonary
disease
• Severe chest trauma
• Mechanical ventilation >
4 days
• Positive gram stain of
tracheal or BAL fluids
Poor
Poor
Ideal
Extended
Angel AJRCCM 2006;174:710-716
Impact of Donor Management Protocol on
Lung Donation and Recipient Outcomes
Angel AJRCCM 2006;174:710-716
Impact of Donor Management Protocol on
Lung Donation and Recipient Outcomes
Angel AJRCCM
2006;174:710-716
Early Donor Management Increases
Retrieval Rate of Lung for TXP
TRIAL
Timing
NON - TRIAL
Within 2 hrs Consent
Continued for 6.9 hrs
OR
Active management using
protocols by on site team
Standard ICU
approach
Pul Art. Cath
2 hours post consent
OR
Fem – A Line
2 hours post consent
OR
EVLWI
Measured
None
PVPI
Calculated
None
Early
OR
1 hour into management
OR
Protocol optimization
for vent/hemodynamics
Bronchoscopy
Trial Meds
Venkateswaran Ann Thorac Surg 2008; 85: 278-86
Early Donor Management Increases
Retrieval Rate of Lungs for TXP
Management Points
•
Commenced Management
• 2 hours post consent
• 12.5 hours post brain death and continued for 6.9 hours
•
Respiratory Management
• Bronchoscopy early
• TV 10 ml/Kg PEEP 5 cm H2O
• Frequent Suctioning
• Volume recruitment by turning every 2 hours
•
Active hemodynamic management
• Specific algorithms for
• CI > 2.5 L/min m2
• CVP and PCWP < 12 mm Hg
• MAP 65-85
• SVR 800-1200 dynes/cm/sec-5 → vasopressin
•
Fluid Resuscitation
• Small amount blood (Hgb > 10 g/dl), gelatin or colloid
• 376 ml of colloid /27 ml crystaloid
Venkateswaran Ann Thorac Surg 2008; 85: 278-86
Early Donor Management Increases
Retrieval Rates of Lungs for TXP
Management Outcomes
• Respiratory function – deteriorated
• ↓ PaO2/FIO2
• ↑ EVLWI and PVPI
• PaO2/FIO2 rose after final inspection
• Bronchoscopy
• Abnormalities in 20 donors
• BAL positive cultures in 31 donors
• Methylprednisolone
• No effect on any absolute indicator
• Associated with reduced accumulation of EVLWI and lower preretrieval PCWP
• Did not improve EVLWI in marginal
• Norepinephrine → PaO2 / FIO2 ratio deteriorated and EVLWI increased
significantly NOT prevented by withdrawal of NE
Venkateswaran Ann Thorac Surg 2008; 85: 278-86
Early Donor Management Increases
Retrieval Rate for Lungs for TXP
Potential Lung Donors (182)
Non Trial Lungs (244)
Trial Lungs (120)
T3 (34)
Placebo (28)
Non-MP Lungs (62)
35.5% Lungs
Retrieval (22/62)
27% Lungs
Transplanted
(66/244)
MP(30) T3 + MP(28)
MP Donors (58)
44.8% Lungs
Retrieval (26/58)
40% Lungs Transplanted
(48/120)
Venkateswaran Ann Thorac Surg 2008; 85: 278-86
Early Donor Management
“Although nontrial donor care was based on a similar
management protocol, albeit without bronchoscopy
or invasive monitoring, management was overseen
by donor procurement coordinators, who are
simultaneously engaged in a logistic process that
includes acquisition of consent, donor family
support, offering of organs to recipient centers,
arranging the multiorgan retrieval procedure, and
transportation of organs and tissue. In contrast, the
donor research fellow was wholly dedicated to donor
management, and we would suggest that this
dedicated donor management role is fundamental to
maximize yield.”
Venkateswaran Ann Thorac Surg 2008; 85: 278-86
3.75 OPD
Subtle Changes or Paradigm Shift?
Joseph Kambe, M.D.
Improving What We Do.


There are short term goals and long term goals.
3.75 Organs per Donor is a short term goal.
Multiple hospitals have shown this is attainable.
 In reality, by paying attention to detail.


Why it happened is not so clear.
Improved because we were looking?
 Is it sustainable across multiple institutions?

Donor Management Goals

If all are met, great results.
If only some are met, variable results.

As an example: CVP and C.O. (BP).

If you met the CVP goal and not use pressors.
 Does this mean you did something useful?
 Or does it mean that the cardio/pulmonary axis was
intrinsically good anyway? Or both?

How Useful is a CVP?

What affects the CVP?
Volume?
 Cardiac Status?
 Pulmonary Status?
 Fluids being infused?
 Patient position?
 Who does the measurement?
 Vasomotor tone?

The Computer: CVP = 17
Would you diurese this patient?
CVP should estimate dLVP
CVP will be falsely high.
Positive pressure ventilation.
PEEP.
Pulmonary disease.
The Clinical Picture



PEEP = 12 cm H2O.
BP = 105/50 mmHg.
CI = 2.3 l/min/m2.
Vasoactive Drugs - Goals


Blood Pressure or Cardiac Output or Both.
One organ perfuses by pressure alone.
HEART: diastolic root pressure - ventricular wall tension.
 Increase myocardial O2 Consumption


All other organs are cardiac output dependent.

There is a point where pressure comes at the expense of
perfusion.
Vasoactive Drugs

Dopamine:
Highest incidence of arrhythmias, organ dysfunction,
death.
 Causes norepinephrine release from the storage granules in
the synapse.
 Does not increase renal blood flow.
 Acts as the antagonist to Renin-Angiotension.
 Recent articles in CCM argue that it should not be used.

Norepinephine



Activity depends on the number of alpha and beta
receptors in the target organ.
Under stimulation receptors are used up.
Only vasoactive drug we do not dose by weight.

Why I know not.
Neosynephrine



Pure alpha agonist.
Causes peripheral vasoconstriction.
In neurogenic shock: there is peripheral
vasoconstriction and cardiac depression.

After-load increase = increased wall tension.
Hormone Replacement
N = 701
Historical Control
Non-Hormone
Replacement
Hormone
Replacement
Age < 40
3.8 opd
4.2 opd
Age > 40
2.5 opd
3.1 opd
So, Why Is this Controversial?

Repeating this has been difficult/impossible.
Used T3, most of us use T4.
 These patients were all fed.
 The Company says T4 is not stable in D5W.
 The Company says T4 is not stable as an infusion.


As of now there is no data about these issues from the Company.
Conversion of T4



T4 is not the active hormone.
T4 must be converted to T3 in the periphery.
This conversion is decreased in illness.


May take up to 8 hours.
Has an immediate action on vasomotor tone.
Actions of T3
Intracellular T3 Activity
T3 Action in the Nucleus

Increases RNA transcription/protein synthesis.


Increases Glucose and protein metabolism.
Where does the fuel for this come from?
Remember in the original article, all were fed.
 We have lost the ability to convert fat into glucose.
 Burning intrinsic protein to make energy.


In illness, studies show giving T4.

Increases organ dysfunction and mortality.
Furthermore

How critical is the 6 – 8 hour delay in T3 function in
terms of repair (protein synthesis)?


Should we all be using T3?
In terms of protein metabolism.
Robbing Peter to pay Paul.
 Protein breakdown to generate energy.


Given the Company’s guidelines.

Are we even giving adequate amounts?
So. What to Make of This?

If we are going to use parameters.
Education. Everyone needs to do it the same way.
 Does it matter? How are we going to find out?



What to do about hormone replacement?
Do we need to upgrade our technology?
There are noninvasive ways to measure C.O.
 Other ways to estimate LV filling pressure.

Plea for a National Database.




Old medical axiom: WNL = we never looked.
If you don’t measure it, you can’t improve it.
Critical Care has spend a lifetime looking.
DMG’s are a beginning to this end.
We need to refine these.
 The larger the numbers the better the accuracy.

DONOR MANAGEMENT GOALS:
Moving Toward a National Strategy
NIL Get Connected Webinar
October 13, 2009
Darren Malinoski, MD
Assistant Professor of Surgery
Director, Surgical Intensive Care Unit
Chair, Organ Donor Council
University of California, Irvine
BACKGROUND
• Donor Management Forum – August 2009
– Intensivists, Transplant Surgeons, OPO representatives,
National Organizations
• Four predominant REQUESTS:
1.Increase Intensivist involvement
2.Increase the science of donor management
3.Tie donor management data to SRTR outcomes
4.Funding for research
PLAN FOR THIS SESSION
•
•
•
•
•
Background on Donor Management Goals (DMGs)
Region 10
Region 5 DMG initiative
Survey Monkey results
National DMG initiative
OTPD and DMGs
3.6
3.4
3.2
OTPD when DMGs
met
OTPD when DMGs
NOT met
OTPD Total
3
2.8
2.6
2.4
2.2
2
Nov-07
Dec-07
Jan-08
Feb-08
CONSENSUS 1 -- 4
•
•
•
•
Sodium < 155
MAP > 60
pH 7.25 – 7.5
CVP < 10
(or serum osmolality 285 – 295)
CONSENSUS 5 & 6
• Pressors 1 or none
(one pressor plus Vasopressin
to treat DI is OK)
• pO2 > 300 if on 100% O2
( or a P/F ratio > 3)
RESULTS FULL YEAR 2008
• 774 TOTAL CASES
• 264 Met Criteria = 34%
• 510 Did not meet criteria = 66%
INCREASE IN ORGANS TRANSPLANTED PER DONOR
WHEN DONOR MANAGEMENT GOALS ARE MET
SORTED BY DONOR TYPE UNOS REGION 10
ORGANS PER DONOR
5
4.5
1.36
4
3.5
3
2.5
1.77
0.59
0.15
2
1.5
1
SCD
ECD
DCD
TOT
DONOR MANAGEMENT GOALS:
The Region 5 DMG Project
Part 1: Retrospective
Part 2: Prospective
PROPOSED DMG’S for REGION

1.
2.
3.
4.
MAP 60-100
CVP 4-10
EF > 50%
</= 1 pressor used AND:
a.
Dopamine </= 10 mcg/kg/min
b.
Neosynephrine </= 100 mcg/kg/min
c.
Norepinephrine </= 10 mcg/kg/min
d.
Vasopressin </= 2.4 units/hour (0.04 units/min)
5.
ABG pH 7.3-7.45
6.
Pao2:Fio2 ratio >300 on PEEP = 5
7.
Serum Sodium 135-160
8.
Urine output 1-3 cc/kg/hour
9.
Glucose < 150
10. Hemoglobin > 10
 Track hormone replacement usage
PART 1 - RETROSPECTIVE
Universal template
 40 SCD’s from each OPO
 Retrospective collection of data regarding proposed
DMG’s (prior to procurement) and organ disposition
information
 Statistical analyses:

–
–
–
–
80% DMG’s = goal met
>/= 4 OTPD = primary outcome measure
DMG-specific results
Other notable findings
DMG’S AND OTPD


Mean # DMG’s with >/= 4 OTPD = 7.2
Mean # DMG’s with < 4 OTPD = 6.1
– T-test: p<0.001

When “goals met”
– Mean OTPD = 4.4
– 70% >/= 4 OTPD

When “goals not met”
– Mean OTPD = 3.3 (t-test, p<0.001)
– 39% >/=4 OTPD (Pearson’s Chi-square, p<0.001)
Multivariate analysis - >/= 4 OTPD
Variable
age
CVP 4-10
EF > 50%
</1 pressor
P:F > 300
Na 135-160
Thyroid hormone
Serum creatinine
OR
0.95
1.7
4.5
1.006
4.8
2.7
1.7
0.612
95% CI
0.93-0.97
0.96-3.1
2.5-8.3
0.51-1.98
2.6-8.6
0.99-7.4
0.97-3
0.4-0.93
p value
<0.001
0.071
<0.001
0.986
<0.001
0.053
0.067
0.022
Moving Forward – Current Project

The Region agreed on 9
DMG’s to prospectively
implement and track for 6
months.

DMG’s will be measured at
consent, 12-18 hours later,
and prior to going to OR

OTPD and graft outcome data
will be analyzed
MAP > 60
 CVP 4-10
 EF > 50%
 </= 1 pressor and low dose
(vasoP eliminated)
 pH 7.3-7.45
 P:F > 300
 Sodium 135-155*
 Glucose < 150
 UOP 1-3 cc/kg/hr over
preceding 4 hours

General Data






Part 1
320 donors
100% SCD
DMG’s prior to OR
Purely retrospective data
DMG’s met = 8/10







Part 2 – July-Dec 2008
492 donors
380 (77%) SCD
DMG’s at 3 time points
Prospective
implementation
DMG’s met = 7/9
Graft Function Data
Can we make a difference or is fate
sealed before we start?
DMG data
(SCD’s only – n=255)
<4 OTPD
(n=132)
>/=4 OTPD
(n=123)
p value
DMG’s at consent (1)
4.5
5
0.001
DMG’s at 12-18 hrs (2)
5.1
6.1
<0.001
DMG’s prior to OR (3)
5.5
6.3
<0.001
Delta DMG 1-2
0.71
1.1
0.050
Delta DMG 2-3
0.3
0.19
0.522
Delta DMG 1-3
1
1.3
0.210
Multivariate analysis – Part 2
>/= 4 OTPD (n=376, 4 missing)
Variable
Age
Terminal creatinine
DMG 1 met
DMG 2 met
DMG 3 met
OR
0.95
0.74
1.9
1.6
2.2
95% CI
0.93-0.96
0.6-0.9
1.02-3.7
0.92-2.6
1.3-3.6
p value
<0.001
0.004
0.044
0.097
0.002
Ejection fraction 3
Pao2:Fio2 3
3.3
3.2
1.8-6
1.6-6
<0.001
0.001
PART 2 CONCLUSIONS

DMG’s are still associated with OTPD

Changes in DMG’s over time are associated with
OTPD

Pre-donor management is associated with
outcomes
SURVEY MONKEY RESULTS
41 OPO’s responding…
Does your OPO use DMGs?
Does your region have a uniform DMG
initiative?
• 38 responses
– YES: 25 (66%)
– NO: 13 (34%)
• More than one response from 9 regions
– One response from region1
– No response from region 6
If your region does not have uniform
DMGs, would you be willing to do so?
Would your OPO be interested in participating
in a National DMG Project?
How important is a National DMG initiative for
advancing the science of donor care?
CONCLUSIONS
• REGION 10:
– Retrospective: Meeting all six DMG’s prior to the OR 
more OTPD
• REGION 5:
– Retrospective and Prospective data suggest that meeting
DMG’s throughout case  more OTPD
• National Survey suggests strong support for DMG’s and
a donor database
Future Directions
Refine DMG’s
Develop Web-based data entry system
Create national DMG’s and donor database
Continue to engage intensivist community
Create a network for large-scale research