Scott Bricker

Arginine vasopressin significantly increases the rate of successful organ procurement in potential donors

BACKGROUND Hormone replacement therapy increases the number and quality of grafts recovered from brain-dead organ donors. Arginine vasopressin (AVP) has also been shown to have beneficial effects. The aim of this study was to determine the effect of AVP on recovery rates. METHODS The Organ Procurement and Transplantation Network database was used. Donors treated with hormone replacement therapy and vasopressor agents who were successfully procured between January 1, 2009, and June 30, 2011, were studied. AVP-positive and AVP-negative donors were compared. The primary study end point was the rate of high-yield procurement (≥4 organs). RESULTS A total of 10,431 donors were included. AVP was infused in 7,873 (75.5%) and was associated with an increased rate of high-yield procurement (50.5% vs 35.6%, P < .001). There was less overall graft refusal due to poor function (38.9% vs 45.6%, P < .001). AVP independently predicted high yield procurement. CONCLUSIONS The use of AVP with hormone replacement therapy is independently associated with an increased rate of organ recovery. This strategy should be universally adopted in the management of donors progressing to neurologic death.

Trends in Organ Donor Management: 2002 to 2012

BACKGROUND Refinements in donor management have resulted in increased numbers and quality of grafts after neurologic death. We hypothesize that the increased use of hormone replacement therapy (HRT) has been accompanied by improved outcomes over time. STUDY DESIGN Using the Organ Procurement and Transplant Network donor database, all brain-dead donors procured from July 1, 2001 to June 30, 2012 were studied. Hormone replacement therapy was identified by an infusion of thyroid hormone. An expanded criteria donor was defined as age 60 years or older. Incidence of HRT administration and number of donors and organs recovered were calculated. Using the Organ Procurement and Transplant Network thoracic recipient database transplant list, wait times were examined. RESULTS There were 74,180 brain-dead donors studied. Hormone replacement therapy use increased substantially from 25.6% to 72.3% of donors. However, mean number of organs procured per donor remained static (3.51 to 3.50; p = 0.083), and the rate of high-yield donors decreased (46.4% to 43.1%; p < 0.001). Incidence of traumatic brain injury donors decreased (42.1% to 33.9%; p < 0.001) relative to an increased number of expanded criteria donors (22.1% to 26%). Despite this, there has been an increase in the raw number of donors (20,558 to 24,308; p < 0.001) and organs (5,857 to 6,945; p < 0.001). There has been an increase in organs per traumatic brain injury donor (4.02 to 4.12; p = 0.002) and a decrease in days on the waiting list (462.2 to 170.4 days; p < 0.001) for a thoracic transplant recipient. CONCLUSIONS The marked increase in the use of HRT in the management of brain-dead donors has been accompanied by increased organ availability overall. Potential mechanisms might include successful conversion of previously unacceptable donors and improved recovery in certain subsets of donors.

Trauma center designation and the decreasing incidence of post-traumatic acute respiratory distress syndrome: A potential guidepost for quality improvement

BACKGROUND The incidence of post-traumatic acute respiratory distress syndrome (ARDS) is decreasing. We hypothesized that disparities exist in the overall incidence and incidence of ARDS over time across different types of trauma centers. METHODS The National Trauma Databank version 7.0 was queried for patients admitted to designated trauma centers (I-III) and ventilated at least 48 hours. Level I university admissions (group 1) were compared with level I community and level II/III center admissions (group 2). RESULTS There were 43,664 patients with an incidence of ARDS of 5.2% (2,260) overall, 4.1% (1,062/25,937) in group 1, and 6.8% (1,198/17,727) in group 2 (P < .001). The incidence decreased significantly in group 1 in contrast to group 2 yearly. The incidence in level I community centers was marked (608/5,180 [11.7%]) and increased significantly over time. On logistic regression, admission to a level I university center (.646 [.590-.707],<.001) was independently associated with ARDS. CONCLUSIONS Admission to a level I center may not necessarily confer similar results reflecting potential variation in management between centers that presumably provide similar service. These investigations may have significance to quality improvement.

The impact of intracranial pressure monitoring on mortality after severe traumatic brain injury.

BACKGROUND The effect of intracranial pressure (ICP) monitoring on mortality after severe traumatic brain injury (sTBI) remains unclear. We hypothesized that ICP monitoring would not be associated with improved survival in patients with sTBI. METHODS A retrospective analysis was performed on sTBI patients, defined as admission Glasgow Coma Scale score of 8 or less with intracranial hemorrhage. Patients who underwent ICP monitoring were compared with patients who did not. The primary outcome measure was inhospital mortality. RESULTS Of 123 sTBI patients meeting inclusion criteria, 40 (32.5%) underwent ICP monitoring. On bivariate and multivariate regression analyses, ICP monitoring was associated with decreased mortality (odds ratio = .32, 95% confidence interval = .10 to .99, P = .049). This finding persisted on propensity-adjusted analysis. CONCLUSIONS ICP monitoring is associated with improved survival in adult patients with sTBI. In addition, significant variability exists in the use of ICP monitoring among patients with sTBI.

The effect of arginine vasopressin on organ donor procurement and lung function

BACKGROUND Hormone replacement therapy (HRT) is becoming more common when managing brain-dead donors. Arginine vasopressin (AVP) is associated with benefits but is not consistently used. We hypothesize that AVP is associated with the maintenance of lung function and successful recovery in donors and enhanced lung graft performance in recipients. METHODS The Organ Procurement and Transplantation Network database was used. Study donors were those treated with HRT and procured from January 1, 2009 to June 30, 2011. AVP (+) and AVP (-) donors were compared. Donor lung function, the rate of successful lung procurement, and the incidence of graft failure in recipients were studied. RESULTS There were 12,322 donors included, of which 7686 received AVP (62.4%). Cerebrovascular accident (4722 [38.3%]) was the most common cause of donor death. There was a significant increase in high yield (≥4 organs) (51.0% versus 39.3%, <0.001), mean number of organs (3.75 versus 3.33, <0.001), and rate of successful lung recovery (26.3% versus 20.5%, <0.001) with AVP. Lung function was preserved to a greater degree in donors receiving AVP. Adjusting the significant factors, AVP was independently associated with lung procurement (1.220 [1.114-1.336], <0.001). The incidence of early graft failure was not changed. CONCLUSIONS AVP with HRT is associated with the maintenance of lung function and a significant increase in successful organ recovery in donors without untoward effects in the recipient. AVP should be universally adopted as a component of HRT in the management of donors with neurologic death.

Donor hormone and vasopressor therapy: closing the gap in a transplant organ shortage.

BACKGROUND Hormone replacement therapy (HRT) use for donors with hemodynamic instability is common. The purpose of this study was to determine the effect of HRT in donors without significant cardiovascular dysfunction and examine outcomes according to vasopressor exposure. METHODS All successfully procured donors admitted between January 1, 2006, and March 31, 2011, were included. HRT group I were donors without significant hemodynamic instability at the initiation of HRT. Comparison was made to all other donors receiving HRT (HRT group II). Vasopressor use was also examined and compared. High-yield procurement was the successful recovery of ≥4 organs. RESULTS Forty-seven donors were studied. Most were male (36 [76.6%]) and trauma (41% [87.2%]) predominated. Twenty-two (46.8%) patients were in HRT group I. There were no differences in gender, admission diagnosis, or complications; however, HRT group I had a significantly greater number of organs recovered (4.73 ± 1.42 vs. 3.08 ± 1.19, p < 0.001). Differences in rates for the heart (68.2% vs. 24%, p = 0.002) and lung (40.9% vs. 8.0%, p = 0.008) were marked. HRT group I was more likely managed on a single agent (45.5% vs. 8.0%, p = 0.003). Norepinephrine was associated with a decreased rate of high-yield procurement (48.0% vs. 77.3%, p = 0.039), while vasopressin exposure was associated with an absolute increase (72.0% vs. 59.1%, p = 0.351). After adjusting for differences between groups (particularly age), HRT group I status was independently associated with high-yield procurement. CONCLUSION A more liberal strategy of HRT seems to significantly increase procurement rates. Vasopressor selection favoring vasopressin as opposed to norepinephrine may also play a role. LEVEL OF EVIDENCE Therapeutic study, level III.

Flat or fat? Inferior vena cava ratio is a marker for occult shock in trauma patients

BACKGROUND Identification of occult shock (OS) or hypoperfusion is critical in the initial management of trauma patients. Analysis of inferior vena cava (IVC) ratio on computed tomography (CT) scan has shown promise in predicting intravascular volume. We hypothesized that a flat IVC is a predictor of OS and associated with worse outcomes in major trauma patients. MATERIALS AND METHODS We performed a 1-y retrospective analysis of our level 1 trauma center database to identify all major trauma activations that underwent evaluation with a CT scan of the torso, arterial blood gas, and serum lactate. A flat IVC was defined as a transverse-to-anteroposterior ratio ≥2.5 at the level of the suprarenal IVC. OS was defined as a base deficit ≥4.0 in the absence of hypotension (systolic blood pressure ≤90 mm Hg). RESULTS Two hundred sixty-four patients were included, of which 52 had a flat IVC. Patients with a flat IVC were found to have a higher injury severity score, lactate, and base deficit compared with patients with a fat IVC. Flat IVC patients also required greater amounts of fluids (P < 0.04) and blood (P < 0.01). On multivariate analysis, a flat IVC was independently associated with an increased risk for OS (odds ratio = 2.87, P < 0.007) and overall complications (odds ratio = 2.26, P = 0.05). The area under the receiver operating characteristic curve for a flat IVC to predict OS was 0.74. CONCLUSIONS A flat IVC on CT is an accurate marker for OS in major trauma victims and may help stratify patients who require more aggressive resuscitation, monitoring, and support.