Meeting clinical goals for the maintenance of the potential organ donor can reduce the loss of donors by cardiac arrest

Introduction

The disproportion between the large organ demand and the low number of transplantations performed represents a serious public health problem worldwide. In Brazil, the loss of transplantable organs from deceased potential donors as a function of cardiac arrest is notably high.

Objective

To test the hypothesis that a goal-directed protocol to guide the management of deceased donors may reduce the losses of potential donors due to cardiac arrest.

Methods

Analysis of all deceased donors reported prospectively to CNCDO/SC, over six 4-month periods between May 2012 and April 2014. Hospitals were encouraged to use a checklist to obtain clinical goals during the management of deceased donors. The checklist was composed of the following goals: protocol duration 12-24 hours, temperature >35°C, mean arterial pressure (MAP) >65 mmHg, diuresis 1-4 ml/kg/hour, corticoids, vasopressin if MAP <65 mmHg, tidal volume 6-8 ml/kg, PEEP 8-10 cmH₂O, sodium <150 mEq/l and blood glucose <180 mg/dl. Effective donors were compared with losses by cardiac arrest. A logistic regression model was used to identify predictors of cardiac arrest with p <0.05.

Results

Of 771 consecutive deceased donors at 27 hospitals, 41 were excluded. Data from the remaining 730 were analyzed. There were 324 (42.0) effective donors, 145 (18.8 %) cardiac arrests, 226 family refusals and 35 contraindications. Compliance with the checklist increased from 52.1 % in the first 4-month period to 85.6 % by the end of 2 years (p <0.001). Cardiac arrests decreased from 19.8 % (first 4-month period) to 14.6 % (sixth 4-month period) over 2 years (p = 0.26). Comparing the sixth 4-month period with the period before the start of the study (26.4 %), there was statistical significance in the latter (p = 0.002), with maintenance of this performance in the two following 4-month periods (Quad 7: 13.8 % and Quad 8: 12.1 %; p <0.001). Factors associated with cardiac arrest reduction were: use of the checklist (OR 0.27, 95 % CI 0.16-0.44, p <0.001) and temperature >35°C (0.79, 95 % CI 0.19-0.79, p = 0.006). The occurrence of cardiac arrests were inversely proportional to the number of interventions (no checklist: 56 %, 0-1: 35 %, 2: 46 %, 3: 38.7 %, 4: 20.2 %, 5: 17.4 %, 6: 12 %, 7: 11 %). More than four interventions had less association with cardiac arrests (30.9 % vs.15.4 %, OR: 0.40, 95 % CI 0.24-0.69, p <0.001).

Conclusion

Meeting clinical goals during the management of deceased donors might reduce the loss of organ donors owing to cardiac arrest.