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. 2016 Oct 11;20(1):323.
doi: 10.1186/s13054-016-1484-1.

Positive impact of a clinical goal-directed protocol on reducing cardiac arrests during potential brain-dead donor maintenance

Glauco A Westphal  1   2   3   4   5   6 , Elisabeth Coll  7 , Rafael L de Souza  8 , Silvana Wagner  8 , Artur Montemezzo  9 , Fernanda Carolina Cani de Souza  9 , Gabriel Torres  9 , Stefan Halla  8 , Tiago C Carnin  8 , Míriam C Machado  10 , Eduardo Berbigier  11 , Fernando Busetto  12 , Ivonei Bittencourt  13 , Karine Gerent  14 , Bruno S de Souza  15 , Manoel Tassinari  16 , Joel de Andrade  8
Affiliations

Positive impact of a clinical goal-directed protocol on reducing cardiac arrests during potential brain-dead donor maintenance

Glauco A Westphal et al. Crit Care. .

Abstract

Background: The disproportion between the large organ demand and the low number of transplantations performed represents a serious public health problem worldwide. Reducing the loss of transplantable organs from deceased potential donors as a function of cardiac arrest (CA) may contribute to an increase in organ donations. Our purpose was to test the hypothesis that a goal-directed protocol to guide the management of deceased donors may reduce the losses of potential brain-dead donors (PBDDs) due to CA.

Methods: The quality improvement project included 27 hospitals that reported deceased donors prospectively to the Transplant Center of the State of Santa Catarina, Brazil. All deceased donors reported prospectively between May 2012 and April 2014 were analyzed. Hospitals were encouraged to use the VIP approach checklist during the management of PBDDs. The checklist was composed of the following goals: protocol duration 12-24 hours, temperature > 35 °C, mean arterial pressure ≥ 65 mmHg, diuresis 1-4 ml/kg/h, corticosteroids, vasopressin, tidal volume 6-8 ml/kg, positive end-expiratory pressure 8-10 cmH2O, sodium < 150 mEq/L, and glycemia < 180 mg/dl. A logistic regression model was used to identify predictors of CA.

Results: There were 726 PBDD notifications, of which 324 (44.6) were actual donors, 141 (19.4 %) CAs, 226 (31.1 %) family refusals, and 35 (4.8 %) contraindications. Factors associated with CA reduction included use of the checklist (odds ratio (OR) 0.43, p < 0.001), maintenance performed inside the ICU (OR 0.49, p = 0.013), and vasopressin administration (OR 0.56, p = 0.04). More than three interventions had association with less CAs (OR 0.19, p < 0.001). After 24 months, CAs decreased from 27.3 % to 14.6 % (p = 0.002), reaching 12.1 % in the following two 4-month periods (p < 0.001). Simultaneous increases in organ recovered per donor and in actual donors were observed.

Conclusions: A quality improvement program based on education and the use of a goal checklist for the management of potential donors inside the ICU is strongly associated with a decrease in donor losses and an increase in organs recovered per donor.

Keywords: Checklist; Donor management; Donor management goals; Organ donor; Organ transplantation.

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Figures

Fig. 1
Fig. 1
Study flowchart. Shaded boxes show the different analyses in the study. CI contraindications
Fig. 2
Fig. 2
Changes in (a) adherence to checklist (%), (b) family decline (%) and contraindications (%), and (c) CAs (%) and actual donors (%) over time. Shaded area refers to 2 years of data collection divided into 4-month periods. White Areas refer to the previous 2 years and the two subsequent quarters of the observation period. *p < 0.01 and **p < 0.05 related to first 4-month period. # p < 0.01 and ## p < 0.05 compared with previous 2 years of the study period
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