Brazilian guidelines for the management of brain-dead potential organ donors
Researchers have recently contributed in updating the recommendations for brain-dead potential organ donor management, as published in the Annals of Intensive Care.
The guidelines were formulated by a group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, all of whom 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.
Main recommendations include-
Ventilatory support
1.We recommend using a lung-protective ventilation strategy in all potential donors (low level of evidence, strong recommendation).
2.We suggest not using alveolar recruitment maneuvers routinely in potential donors (very low level of evidence, weak recommendation).
Hemodynamic support
Volemic expansion and vasopressors
3.We recommend performing initial volemic expansion in hemodynamically unstable potential donors with hypovolemia or responsive to fluids according to fluid responsiveness assessment (good clinical practice).
4.We recommend administering norepinephrine or dopamine to control blood pressure in potential donors who remain hypotensive after volemic expansion (very low level of evidence, strong recommendation).
5.We suggest not using low-dose dopamine for renal protection in potential donors (very low level of evidence, weak recommendation).
Endocrine and electrolyte management
Hormones
6.We recommend combining arginine vasopressin (AVP) in potential donors receiving norepinephrine or dopamine to control blood pressure (low level of evidence, strong recommendation).
7.We recommend administering AVP or 1-deamino-8-D-arginine vasopressin (DDAVP) to control polyuria in potential donors with diabetes insipidus (low level of evidence, strong recommendation).
8.We suggest using low-dose corticosteroids in potential donors receiving norepinephrine or dopamine to control blood pressure (low level of evidence, weak recommendation).
9.We suggest not using thyroid hormones routinely in potential donors (very low level of evidence, weak recommendation).
10.We suggest performing glycemic control in potential donors (very low level of evidence, weak recommendation).
Electrolytes
11.We suggest maintaining serum sodium levels below 155 mEq/dL in potential donors (very low level of evidence, weak recommendation).
12.We recommend maintaining serum potassium levels between 3.5 and 5.5 mEq/L in potential donors (very low level of evidence, strong recommendation).
13.We recommend maintaining serum magnesium levels above 1.6 mEq/L in potential donors (very low level of evidence, strong recommendation).
Other aspects of potential donor management
Nutritional support
14.We suggest maintaining nutritional support in potential donors if well tolerated (very low level of evidence, weak recommendation).
Infection and sepsis
15.We recommend using antibiotics in potential donors with infection or sepsis (low level of evidence, strong recommendation).
Body temperature control
16.We suggest maintaining body temperature above 35 °C in hemodynamically unstable potential donors (very low level of evidence, weak recommendation).
17.We suggest inducing moderate hypothermia (34–35 °C) in potential donors without hemodynamic instability (low level of evidence, weak recommendation).
Red blood cell transfusion
18.We suggest transfusing packed red blood cells in potential donors with hemoglobin levels g/dL (very low level of evidence, weak recommendation).
Goal-directed protocols
19.We suggest using a goal-directed protocol during the management of potential donors (very low level of evidence, weak recommendation).
Hence, the panel members concluded that "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."
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