Abstract
ObjectiveTo contribute to updating the recommendations for brain-dead potential organ donor management.MethodA group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020.ResultsA total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion).ConclusionDespite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.
Highlights
Organ donation for transplantation is a complex process led by several health care professionals responsible for a sequence of actions and procedures that begin with identifying a potential organ donor and end with organ procurement surgery and distribution
The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors
Given the marked clinical instability that occurs in patients who progress to brain death, the application of potential donor-management strategies aiming at hemodynamic stabilization is crucial to avoid loss of organs due to hypoperfusion or loss of donors due to cardiac arrest
Summary
A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong, 11 as weak, and 1 was considered as good clinical practice. Summary of evidence alveolar recruitment maneuvers have been suggested for the ventilatory management of organ donors with lung injury (PaO2/ FiO2 < 300) [13,14,15,16, 18, 20], and these maneuvers could reduce hypoxemia after apnea testing, contributing to increasing the viability of pulmonary grafts [14,15,16,17,18, 20], a randomized clinical trial showed unfavorable outcomes in critically ill patients [21]. In cases of hypoxemia refractory to the lung-protective ventilation strategy, alveolar recruitment maneuvers should not be performed routinely Their use is not indicated in hemodynamically unstable potential donors. Targeting a mean arterial pressure (MAP) ≥ 65 mm Hg has been associated with reduced occurrence of cardiac arrest in potential donors
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