Brazilian guidelines for the management of brain-dead potential organ donors

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."