Improving Organ Yield With Advanced Hemodynamic Monitoring

Reid B. Freeman; Jason M. Walker

Disclosures

August 24, 2018

The number of registered organ donors in the United States is steadily growing, but the number of individuals needing organs is also increasing. Every day, approximately 20 people die waiting for a lifesaving transplant. Efforts are under way by the donation and transplant community to increase the supply of organs needed to meet the increasing demand.

Technological advances, such as the use of improved algorithms to efficiently match donors to recipients, are succeeding in increasing the number of organs available for transplant. At the Southwest Transplant Alliance (STA) in Dallas, we have been able to significantly increase the yield of donor organs by using various technologies to improve donor management, such as an advanced hemodynamic monitoring system.

The use of clinical and monitoring technologies during transplant cases can help ensure optimal donor selection and organ function pre- and posttransplant. For example, the use of dialysis to remove fluid in donors with acute kidney failure can improve the viability of the kidneys, lungs, and heart for donation. Digital pathology allows transplant surgeons to remotely view biopsy slides of kidneys and livers on their smartphone and make immediate decisions about whether to use those organs for transplant.

Individuals who are potential organ donors have often suffered trauma and typically present to the hospital overloaded with blood and other fluids used in the resuscitation attempt. For these donors, determining fluid status can help transplant coordinators make informed decisions about whether to administer or withdraw certain medications or add or remove fluid in order to maximize the function of the lungs. This not only helps improve the suitability of the lungs for transplant, but also improves the function of the heart and other organs, such as the kidneys and liver, which makes them suitable for transplantation as well.

Using Hemodynamic Monitoring to Guide Donor Management

The use of an advanced hemodynamic monitoring technology, called PiCCO (Pulse Contour Cardiac Output), to monitor physiologic parameters is useful for these donors. This technology calculates pulse contour, which provides continuous information, and transpulmonary thermodilution, which provides static measurements and is used to calibrate the continuous pulse contour parameters.[1,2] The PiCCO catheter integrated sensor detects very precise parameters of the heart and lungs and thus can determine intravascular and extravascular fluid status as well as assess pulmonary edema.[3]

The following case studies illustrate how we successfully used this advanced hemodynamic monitoring technology as part of a donor management strategy:

  • 36-year-old female: death due to a cerebral accident. History of type 2 diabetes, smoking (15 pack-years), and obesity (body mass index [BMI], 40 kg/m2). The donor was severely hypernatremic (sodium level, 171 mEq/L) when donor management began. Fluid volume was resuscitated over 2 days to normalize sodium to 150 mEq/L. Initial P/F ratio was compatible with acute respiratory distress syndrome. Phenylephrine and norepinephrine were administered to maintain stable blood pressure. Throughout the next few days, the donor was weaned off vasopressors. Initial PiCCO values showed the donor to be volume-responsive and hypovolemic. Extravascular lung water index (ELWI) was maintained within a 3-point margin throughout medical management. Initial ELWI was 10, and terminal ELWI was 11. The kidneys were damaged during recovery and submitted for research. The heart was allocated for 24 hours with no success and was submitted for research. Both lungs were recovered and transplanted locally, and the liver was recovered and shared regionally.

     

  • 36-year-old male: death due to suicide (hanging). Experienced 5 minutes of asystole and 25 minutes of cardiopulmonary resuscitation. No past medical history. Donor was initially 2 L fluid positive on his intake and output. Initial PiCCO values were grossly normal. Fluid volume was resuscitated because of elevated creatinine level of 2.1 mg/dL. Final fluid volume status was positive (11.5 L), and creatinine decreased to 1 mg/dL. ELWI was maintained within a 2-point margin with minimal pulmonary protection owing to vigilant ELWI monitoring. Donor management was accomplished with severe cardiac compromise (ejection fraction, 33%). Both lungs, the liver, and both kidneys were recovered and transplanted.

     

  • 48-year-old female: death due to cardiac arrest after a drug overdose. History of hypertension and obesity (BMI, 40 kg/m2). Initial fluid balance documented was even. The donor remained hypertensive with decreased sodium on antihypertensive drips. Donor management strategy was implemented to include fluid shift and fluid reduction. Initial PiCCO numbers were grossly normal, with ELWI of 9. After the fluid shift, ELWI increased to 18, but decreased to 10 with diuresis throughout the course of donor management. Total fluid balance ended at -6 L. Both lungs, the heart, the liver, and both kidneys were recovered and transplanted.

We also assessed this technology in a 12-month retrospective trial using organs transplanted per donor (OTPD) data.[4] We compared 83 donors monitored with PiCCO for whom we were evaluating lungs for transplant with two control groups: 104 donors monitored with FloTrac™ (another hemodynamic monitor that provides cardiac output information solely via pulse contour analysis) and 261 donors monitored with standard hemodynamic monitoring. During this time frame, the national average for OTPD was 3.04. Our results demonstrated (Table):

Table. OTPD With Use of PiCCO Versus Other Systems

Group Number of Organs Procured OTPD
PiCCO: 83 donors 317 3.82
FloTrac: 104 donors 363 3.46
No advanced hemodynamic monitoring: 261 donors 673 2.57

OTPD = organs transplanted per donor; PiCCO = Pulse Contour Cardiac Output

The use of the advanced hemodynamic monitoring system improved STA transplant coordinators' awareness of the donor's intravascular and extravascular fluid status. This allowed them to devise a management strategy that resulted in a substantial increase in the yield of organs per donor with PiCCO—about 10% more than with the FloTrac technology and about 40% more than with no advanced hemodynamic monitoring—and not just lungs but also kidneys, livers, pancreases, and intestines. Using these technology advances, STA was able to recover more than 1200 organs from donors in 2017 and remove patients from the waiting list, saving countless lives.

In conclusion, the adoption of new technologies by transplant teams and organ procurement organizations to guide donor management, including advanced hemodynamic monitoring, can help improve organ function and increase the number of life-saving organs available for transplant.

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