The objective of this guideline is to update the existing Canadian recommendations for the medical management of neurologically deceased ("braindead") adult and pediatric potential donors for the purposes of single or multiorgan recovery for transplantation and Ms. Vanya Lang, the donor family member and patient partner, whose experiential perspectives kept this initiative focused on the overarching purpose: providing highquality endoflife care for deceased organ donors and improving outcomes for transplant recip ients. The authors acknowledge the information services support they received to design and execute the search strategies for the sys tematic reviews used to inform this guideline:# D
emand for organs continues to exceed their availability, both in Canada and around the world. 1 Optimizing the medical management of potential organ donors is an important strategy for enhancing organ supply. The explicit goals for management of deceased organ donors in the intensive care unit (ICU) are to stabilize the potential donor and to optimize the number and quality of organs for transplantation.
In 2006, the Canadian Council for Donation and Transplanta tion produced the first Canadian recommendations for organ donor management, 2 the result of a 2004 forum -Medical Man agement to Optimize Donor Organ Potential -in collaboration with the Canadian Critical Care Society, the Canadian Associa tion of Transplantation and the Canadian Society of Transplanta tion. This forum was the first structured, cooperative assembly of health care professionals in the fields of critical care medicine and transplantation and was a landmark event in Canadian organ donation practice. 2 The 2006 guideline had an influence on organ donation recommendations internationally;  however, it had not been updated to incorporate emerging evidence in organ donor management and critical care medicine and the many advances in guideline development methodology. 7 The objective of this guideline is to update the existing Can ad ian recommendations for the medical management of neuro logically deceased ("braindead") adult and pediatric potential donors for the purposes of single or multiorgan recovery for transplantation. (The full guideline is available in Appendix 1, at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.190631//DC1.)

# Scope
The scope of this guideline is the management of the potential organ donor, beginning at the time of the neurologic determination of death and ending at the time of transfer to the surgical recovery team. This includes all aspects of medical care in the ICU for adult and pediatric organ donors: monitoring, investigations, somatic sup port, preventive care, drug administration and technical procedures.
Aspects of deceased donation that are not in the scope of this guideline include ICU interventions that precede death by neuro logic criteria, the neurologic determination of death, donation after a circulatory determination of death, donation after med ical assistance in dying, organ allocation procedures, anesthetic and surgical procedures related to organ recovery or transplan tation, and management of the organ recipient.
The clinical practice and ethics of starting donor manage ment interventions before neurologic determination of death are not addressed by this guideline.
The target users of this guideline include organ donation organizations, policymakers, administrators and clinicians who manage neurologically deceased organ donors.

# GUIDELINE CPD

# Management of the neurologically deceased organ donor: A Canadian clinical practice guideline
- We suggest against routine administration of thyroid hormone in neurologically deceased potential donors.
- We suggest against routine coronary angiography in neurologically deceased potential donors being assessed for heart donation.
- We suggest maintaining the body temperature of neurologically deceased potential donors in the range of 34C to 35C, unless kidneys will not be used for transplantation.
- We recommend a lungprotective ventilation strategy consisting of low tidal volumes (6-8 mL/kg), high positive endexpiratory pressure (at least 8 cm H 2 0) and recruitment manoeuvres performed after ventilator disconnections in neurologically deceased potential lung donors.

# Recommendations
This clinical practice guideline is intended for use in the care of both neurologically deceased adult and pediatric potential organ donors. We based our recommendations on organ donor man agement literature from both age groups, although we discov ered very little pediatricspecific literature. All recommendations apply to pediatric and adult donors, except for the minimal acceptable blood pressure, which should be age adjusted in pediatric patients.
We make 1 strong recommendation, 30 conditional recom mendations, 1 "good practice" statement and 4 "no recommen dations." Readers will note that the preponderance of donor management literature is limited to lower levels of evidence. The authors acknowledge recent studies (published after this guide line was submitted) in this area, but these do not change the direction and certainty of the recommendations. More informa tion on the evidence supporting each recommendation is avail able in the full guideline document (Appendix 1).
This synopsis provides information on 4 recommendations that the steering committee deemed likely to have the most impact on clinical practice. A complete summary of all recom mendations is available in Table 1.

# Thyroid hormone administration
We suggest against routine thyroid hormone supplementation (conditional recommendation, low-certainty evidence).
We make no recommendation about thyroid hormone supplementation for patients with hemodynamic instability or cardiac dysfunction.
Endogenous catecholamine release is increased during both acute critical illness and neurologic death. Although this causes an increase in systemic vascular resistance, cardiac output is compromised by neurologic death-induced myocardial suppres sion and a decrease in thyroid hormone release owing to pitu itary failure.  This state has the potential to compromise trans plantation of the heart itself and other organs as a result of impaired perfusion. There is therefore a theoretical advantage to exogenous thyroid hormone supplementation.
Four randomized controlled trials (RCTs)  assessed the effect of thyroid hormone on donor hearts and showed no improvement in the number of hearts eligible for transplanta tion. These studies were included in a 2012 systematic review, 15 which concluded there was no benefit from any form of thyroid hormone for neurologically deceased potential donors. We excluded 3 other RCTs included in the 2012 systematic review from our analysis as they did not report on any of our outcomes of interest (e.g., reported only on biochemical markers). All of these RCTs included several cointerventions administered to both the intervention and control groups.
In addition to the RCTs, we identified 5 observational studies  that reported conflicting results regarding the effect of treatment with thyroid hormone on the number of transplanted hearts. In the largest cohort study of 63 593 patients, 21 patients who received thy roid hormone had a 9.23% higher rate of heart recovery. Two addi tional cohort studies described a multivariate model that included thyroid hormone as a covariable associated with an increased chance of heart transplant eligibility. 22,23 Thus, for our primary out come of interest -number of hearts transplanted -the evidence suggests that thyroid hormone is of little benefit, although some larger cohort data suggest increased cardiac recovery.
The guideline panel did consider other outcomes, including cardiac function prerecovery, total number of organs recovered, graft survival and patient survival. Only cardiac function pre recovery was assessed in RCTs and no significant improvement was observed.  Cohort data, primarily from the large United Network for Organ Sharing report, 21 suggest that thyroid hor mone replacement is associated with increased cardiac graft and patient survival at 1 and 12 months, and increased number of organs recovered. Although these findings were statistically sig nificant, their interpretation is complicated by the fact that most patients received thyroid replacement as part of a hormone ther apy bundle and the effect of thyroid alone is difficult to assess.
Given the absence of established benefit in RCTs comparing thyroid hormone to no thyroid hormone, and the conflicting observational evidence, we suggest against the routine use of thyroid hormone in all potential donors.
We acknowledge that it is accepted practice in many centres to administer thyroid hormone to patients with cardiac dysfunc tion and that a recommendation against doing so in this sub group would have added acceptability and feasibility issues. We also acknowledge that there is no published evidence of physio logic harm associated with the administration of thyroid hor mone in this context. Given the absence of comparative evidence (RCTs or observational) in this higherrisk population and the potentially substantial acceptability issues, the committee felt the benefits and harms were very closely balanced. As such, we make no recommendation in the subgroup of patients with hemodynamic instability or cardiac dysfunction.

# Coronary angiography
We suggest against routine coronary angiography (conditional recommendation, very low-certainty evidence).

# Coronary angiography should be performed in the presence of risk factors for coronary artery disease as determined according to local criteria (good practice statement).
The evidence addressing the benefits of coronary angiography in potential heart donors is of very low quality. There is only 1 study that directly addresses this question. In this retrospective cohort study, Hauptman and colleagues 24 compared the rates of early graft failure in recipients who received a heart from a donor who underwent coronary angiography versus those who received hearts from donors who did not undergo coronary angiogram. Recipients who received a heart from donors who had an angio gram were less likely to have early graft failure. 24 No adverse effects were reported. This was a retrospective, nonrandomized study with low internal validity. - We suggest intravenous vasopressin as a firstline vasoactive agent for hypotension (conditional recommendation, very lowcertainty evidence).
- We suggest intravenous norepinephrine as a secondline agent for hypotension not responding to vasopressin alone (conditional recommendation, very lowcertainty evidence).
- We suggest against the use of dopamine at any dose (conditional recommendation, lowcertainty evidence).
- We make no recommendation regarding other vasoactive medications and inotropes.

# Antihypertensive medications
- We suggest using shortacting intravenous antihypertensive agents as per standard ICU practice to prevent endorgan damage (conditional recommendation, very lowcertainty evidence).

# Minimal acceptable blood pressure target
- We suggest maintaining mean arterial pressure  65 mm Hg rather than a lower threshold (conditional recommendation, very lowcertainty evidence).

# Fluid resuscitation
- We suggest infusing crystalloids, rather than colloids, for plasmavolume expansion (conditional recommendation, lowcertainty evidence).

# Protocolized fluid management
- We make no recommendation regarding the use of fluid management protocols.

# Glycemic control and nutrition

# Glucose control
- We suggest maintaining serum glucose levels in the range of 6-10 mmol/L, rather than a lower range of 4-6 mmol/L (conditional recommendation, very lowcertainty evidence).

# Glucose, insulin and potassium administration
- We suggest against the infusion of combined solutions of glucose, insulin and potassium (conditional recommendation, very lowcertainty evidence).

# Nutritional support
- We suggest providing enteral nutrition as compared with no nutritional support (conditional recommendation, very lowcertainty evidence).

# Diabetes insipidus and hypernatremia

# Serum sodium control
- We suggest maintaining serum sodium concentration in the normal range (135-155 mmol/L) (conditional recommendation, very lowcertainty evidence).

# Diabetes insipidus and vasopressin
- We suggest treating diabetes insipidus with desmopressin or vasopressin during hemodynamic stability (conditional recommendation, very lowcertainty evidence).
- We suggest treating diabetes insipidus with vasopressin during hemodynamic instability (conditional recommendation, very lowcertainty evidence).

# Hormonal therapy

# Thyroid hormone
- We suggest against routine thyroid hormone supplementation (conditional recommendation, lowcertainty evidence).
- We make no recommendation about thyroid hormone supplementation for hemodynamic instability or cardiac dysfunction.

# Corticosteroids
- We suggest intravenous corticosteroid therapy for donors requiring vasopressor support (conditional recommendation, lowcertainty evidence).
- We make no recommendation about highdose corticosteroid therapy for potential lung donors.

# Transfusion therapy

# Transfusion threshold
- We suggest withholding red blood cell transfusions unless hemoglobin levels fall below 70 g/L (conditional recommendation, very low certainty in evidence).

# Correction of coagulopathy and thrombocytopenia
- We suggest that in the absence of clinically significant bleeding, transfusions of fresh frozen plasma be withheld altogether, and that platelet transfusions be withheld unless platelet levels fall below 10  10 9 /L (conditional recommendation, very low certainty in evidence).
We also considered the logistics of coronary angiography. Coronary angiography requires patient transport outside of the ICU, exposes the donor organs to potentially harmful intra arterial contrast, is not available in all centres where patients who are potential donors are admitted, and is relatively costly and resource intensive.
Considering the limited evidence of benefit and the risks described above, we suggest against using routine coronary 

# Bacterial infections

# Antibiotics
- We suggest reserving antibiotic therapy for the treatment of known or suspected infection (conditional recommendation, very lowcertainty evidence).

# Routine cultures
- We suggest that screening cultures of blood, urine and sputum be performed at intervals consistent with general ICU practice and patient clinical status (conditional recommendation, very lowcertainty evidence).

# Organ-specific considerations: heart, lungs and intra-abdominal organs

# Cardiac assessment tools
- We suggest against routine use of pulmonary artery catheters (conditional recommendation, very lowcertainty evidence).
- We suggest serial echocardiography at intervals consistent with general ICU practice (conditional recommendation, very lowcertainty evidence).

# Cardiac biomarkers
- We suggest against the measurement of serum cardiac biomarkers (conditional recommendation, very lowcertainty evidence).

# Coronary angiography
- We suggest against routine coronary angiography (conditional recommendation, very lowcertainty evidence).
- Coronary angiography should be performed in the presence of risk factors for coronary artery disease as determined according to local criteria (good practice statement).

# Lung-protective ventilation
- We recommend a lungprotective ventilation strategy consisting of low tidal volumes (6-8 mL/kg), high positive endexpiratory pressure (at least 8 cm H 2 0) and recruitment manoeuvres after ventilator disconnections in potential lung donors (strong recommendation, moderate certainty evidence).

# Bronchoscopy
- We suggest diagnostic bronchoscopy be performed for potential lung donors (conditional recommendation, lowcertainty evidence).

# Inhaled -agonist therapy
- We suggest against routine use of inhaled agonists (conditional recommendation, moderatecertainty evidence).

# Chest radiography and computed tomography scan
- We suggest a single routine diagnostic chest radiograph for lung donors and additional chest imaging as clinically indicated (conditional recommendation, lowcertainty evidence).

# Albumin: creatinine ratio screening
- We suggest using the albumin:creatinine ratio for detecting microalbuminuria when assessing potential kidney donors with type 1 or 2 diabetes mellitus (conditional recommendation, very low certainty in evidence).

# Hemoglobin HbA 1c testing
- We suggest that hemoglobin HbA 1c testing be performed in potential donors being considered for pancreas donation (conditional recommendation, very lowcertainty evidence).

# Abdominal imaging
- We suggest that abdominal CT or ultrasound should be used only in those with age > 50 yr, comorbid conditions, high body mass index, or clinical history of malignancy (conditional recommendation, lowcertainty evidence).

# Other therapeutic interventions

# Therapeutic hypothermia
- We suggest maintaining the core body temperature in the range of 34C-35C, unless kidneys will not be used for transplantation, in which case normothermia is appropriate (conditional recommendation, lowcertainty evidence).

# Duration of donor management
- For potential donors with acute organ injury, we make no recommendation regarding timing of organ recovery surgery or optimal duration of ICU donor management (conditional recommendation, very lowcertainty evidence).
Note: CT = computed tomography, HbA1c = glycosylated hemoglobin, ICU = intensive care unit.
angiography. As a good practice statement, however, we suggest that coronary angiography be considered in donors with risk fac tors for coronary artery disease because despite the lack of sup porting evidence for angiography in this clinical situation, it is expected that the benefit of avoiding transplant of a heart with coronary artery disease will outweigh the risk related to logistics and intraarterial contrast.

# Lung-protective ventilation
We recommend a lung-protective ventilation strategy consisting of low tidal volumes (6-8 mL/kg), high positive end-expiratory pressure (PEEP) (at least 8 cm H 2 0) and recruitment manoeuvres after ventilator disconnections in potential lung donors (strong recommendation, moderate-certainty evidence).
Ventilation with low tidal volumes is the standard of care for many ICU patient populations and is supported by experimental evidence and physiologic rationale. Some of the highestquality evidence in organ donor management is in the area of donor ventilation.
We defined a lungprotective ventilatory strategy as low tidal volumes, high PEEP and recruitment manoeuvres. We were unable to identify literature that evaluated any of these 3 com pon ents in isolation. One RCT and 3 observational studies exam ined mechanical ventilation with a lungprotective approach in neurologically deceased potential donors.  The RCT com pared a lungprotective approach (tidal volumes of 6-8 mL/kg predicted body weight, PEEP 8-10 cm H 2 O, recruitment manoeu vres after disconnections from the ventilator (and an additional protocol for apnea testing) to conventional ventilation (tidal vol umes > 8 mL/kg predicted body weight, PEEP< 8 cm H 2 O, no pro tocolized recruitment manoeuvres and apnea tests off the venti lator). 25 The protective strategy was continued for a minimum of 6 hours, and potential donors assigned to this strategy were twice as likely to proceed to lung procurement. There was no sig nal of harm among the lung recipients; nor was there any signal of harm from the protective ventilation strategy with respect to the recovery of other organs.
Three observational studies with historical control groups evaluated the effect of a comprehensive lungdonor manage ment strategy.  Two of these studies involved the ventilation protocol tested in the RCT. 26,27 The third study involved higher PEEP of 15 cm H 2 O, without the other components of lung protective ventilation. All 3 studies showed an improved lung procurement rate with implementation of their comprehensive lung donor management strategies, and 1 of the 3 studies showed increased recipient survival. 28 The committee considered potential drawbacks not explored in these studies. First, as was the case in all the studies, the criteria for lung donation eligibility frequently involves the ratio of arterial oxygen partial pressure to fractional inspired oxygen (Pao 2 :FiO 2 ratio) as a measure of lung function. However, PEEP is a therapeu tic intervention that may transiently improve the Pao 2 :FiO 2 ratio in some physiologic states.  Thus, there is a risk that high PEEP ventilation allows relatively suboptimally functioning lungs to appear numerically viable for transplant at the time of eligibility assessment. In the RCT, lungprotective ventilation was not associ ated with an increase in criterioneligible lungs being declined based on gross inspection or other surgical opinion. 25 Second, increasing mean airway pressure via increased PEEP has the potential to decrease cardiac output. 32 It is possible that the decreased cardiac output outweighs any benefit on graft oxy gen delivery derived from improved arterial oxygenation. In the donation population, this may be best assessed through the viability of other organs in potential donors managed with lung protective ventilation, but this outcome was not reported in the included studies.
Given that the evidence for a benefit from lungprotective ventilation is greatest for lung donation, we considered narrow ing our recommendations to potential lung donors only. How ever, the candidacy of specific organs for donation is often not known in the early stages of donor care, and a delay in initiating lungprotective ventilation will reduce its benefit. We therefore recommend that lungprotective ventilation be started as soon as possible in all potential neurologically deceased donors. Intensivists and respiratory therapists are experienced with lung protective ventilation in the critically ill, and this approach does not incur any additional costs with respect to equipment or human resources. We therefore do not expect major barriers to implementing this recommendation routinely in neurologically deceased donors.

# Therapeutic hypothermia
We suggest maintaining the core body temperature in the range of 34-35C, unless kidneys will not be used for transplantation, in which case normothermia is appropriate (conditional recommendation, low-certainty evidence).
In the single RCT in this area, 33 the induction of mild therapeutic hypothermia (34C-35C) in donors was shown to reduce the occur rence of delayed graft function in kidneys, a benefit that was even more substantial in the extended criteria donor population. There was no evidence of harm in the intervention group and the recovery of other organs was not affected in the hypothermia group. Graft outcome of other transplanted organs was not reported.
A retrospective analysis of mild spontaneous hypothermia (< 36C) was performed from a data set designed to study dopa mine in the organ donor population. 34 Similarly to the RCT described above, the study showed a reduction in kidney delayed graft function in the hypothermia group. There was no difference in 5year graft survival. The same data set used to study cardiac donors identified a lower 3year graft survival in donors with spontaneous temperature less than 36.2C. 35 Given the methodological limitations of studying spontaneous hypo thermia, causation versus association for outcomes was an issue; evidence was downgraded to low.
Targeted temperature management is now common practice in most critical care units. Although there are only 3 studies evalu ating this intervention in organ donors, the absence of any identified harm, combined with the fact that the most commonly recovered organ is the kidney, led our guideline committee to suggest mild hypothermia in all organ donors until kidneys have been ruled out for donation.
We acknowledge that there are minimal data on the effect of mild hypothermia on nonrenal organs and that the evidence for cardiac donors is weak. New evidence could change this recom mendation. The considerations for hypothermia are stronger when only kidneys are considered in an extended criteria donor. The 23member guideline panel selected by the steering com mittee included representation from critical care medicine (adult and pediatric), critical care nursing and pharmacy; an infectious disease specialist; organ donation specialist physicians; and peo ple with organspecific expertise in transplant cardiology, cardiac surgery, pulmonology, lung surgery, urology, nephrology and abdominal surgery. We included 2 patient partners, a family mem ber of a deceased multiorgan donor and a heart transplant recipi ent. Other panel members included representatives from specific knowledge user groups: the Canadian Critical Care Society, the Canadian Society of Transplantation, the Canadian Association of Critical Care Nurses and the Canadian Donation and Transplanta tion Research Program. By design, the guideline panel included geographic diversity from 4 provinces (Ontario, Quebec, Alberta and BC), representing the most active donation and transplant programs in Canada. The full participant list and description of the guideline methodology is available in Appendix 1.

# Methods

# Guideline panel composition
Canadian

# Guideline development
We reviewed the results of a systematic review of published organ donor management guidelines 36 before deciding on the scope of our effort. This review of 27 guidelines from 22 countries provided an overview of topics that had been covered by other groups and informed our list of 29 potential PICO (Patient, Inter vention, Comparator, Outcome) questions (Appendix 1).
The guideline panel was divided into 3 smaller working groups that selected outcomes of interest for each question. The overall group explicitly rated these outcomes for their relative importance from "not important" to "critical" according to GRADE guidance. 37 In cases of disagreement, decisions were made by group discussion and consensus. We developed a hier archy of outcomes to inform these discussions: clinical optimiza tion during the interval between death declaration and organ recovery; increased organ acceptance, recovery and transplanta tion; an increase in organ recovery; improved graft function; graft survival; and recipient survival and quality of life.
Within the 3 working groups, panel members were assigned PICO questions in pairs and collaborated with information technologists or medical librarians to design and conduct search strategies for each of the 29 PICO questions. Our population of interest was neurologically deceased organ donors. Primary searches were limited to human studies reported in English, either in full text or abstract. At minimum for each question, we searched MEDLINE (PubMed) and the Cochrane Central Register of Controlled Trials (CENTRAL). Primary searches were restricted to human studies reported in English, from 1981 to present, either in full text or abstract (see Appendix 1 for details of the search strategies, including individual end dates). Two panel members independently screened all relevant citations of each PICO question for eligibility. Disagreements were resolved through consensus and discussion. Searches were completed by September 2018. Steering committee members monitored the literature up until January 24, 2020, for recent publications that could affect the direction or certainty of any recommendations.
In situations where little to no direct research evidence was available in the organ donation or transplantation population, we extended our search to indirect evidence. In most cases, this referred to studies in the general ICU population, but in some cases, it included animal studies or trials in other patient populations.
In their assigned pairs, panel members abstracted study char acteristics and outcome data from all eligible studies for each PICO question. In addition to clinical data, we also assessed indi vidual study risk of bias using the Cochrane Risk of Bias tool 38 for RCTs and the Newcastle-Ottawa tool 39 for observational studies. When possible, we pooled outcome data for each PICO question and performed metaanalyses using the Cochrane Collaboration Review Manager 5.2. 40 Once this analysis was completed, we assessed the overall certainty (confidence) in the effect estimate for each outcome of interest following the GRADE approach 41 based on these criteria: risk of bias, precision, consistency, directness of the evidence, risk of publication bias, presence of a dose-effect relationship, magnitude of effect and an assessment of the effect of plausible residual confounding or bias. Consider ing all of these elements, the strength of evidence for each out come was categorized as high, moderate, low or very low. Steer ing committee members with GRADE expertise and experience (B.R. and L.H.) oversaw this process.
Pairs of panel members prepared evidence summaries for each question in collaboration with the methodologist (B.R.), fol lowing the GRADE approach 42 and using the GRADEpro Guideline Development Tool online software. 43 Based on these evidence summaries, the 3 working groups devel oped recommendations for each PICO question. We used the GRADE Evidence to Decision framework to facilitate discussion on each rec ommendation. 44 Recommendation development was based on the certainty of the evidence, the balance of desirable and undesirable consequences of compared management options, assumptions about the values and preferences associated with the decision, implications for resource use and health equity, the acceptability of an intervention to stakeholders, and feasibility of implementation. The guideline panel assessed each recommendation for pediatric specific considerations. The 3 working groups presented their rec ommendations to the entire guideline panel for further review and discussion. Disagreements were resolved by consensus.
In accordance with the GRADE approach, 45 we used the phrasing "we recommend" for strong recommendations and "we suggest" for conditional recommendations. Table 2 pro vides a guide to interpretation of these recommendations for intended stakeholders, including patients, clinicians and health policymakers.
The guideline panel endeavoured to provide recommenda tions for each original PICO question. In the exceptional circum stance where there was insufficient evidence for or against an intervention, or if there was a perceived balance between net benefits and net harms, then the panel made "no recommenda tion." "Good practice statements" were made when there was a high level of certainty about the effect of the therapy, but little direct supporting evidence. 47 

# External review
Representatives of the supporting organizations, including the Canadian Critical Care Society, the Canadian Society of Trans plantation and the Canadian Association of Critical Care Nurses, performed external reviews. The lead author (I.B.) incorporated the feedback into the guideline and steering committee mem bers edited it. The entire guideline panel had an opportunity to review the final version of the guideline.

# Management of competing interests
All guideline panel members signed a confidentiality agreement at the inaugural meeting in 2017, where they were also asked to disclose any potential direct and indirect competing interests using a Canadian Blood Services competing interests documen tation form. These were collected again a year later and before publication. Canadian Blood Services personnel and the steering committee reviewed the declarations. Several panel members have professional roles in organ donation administration, with governmental notforprofit entities, or have funded scientific research; however, no steering committee or panel member was judged to have a relevant direct competing interest.

# Implementation
No specific dosing regimens were recommended for either pedi atric or adult patients, and groups planning to use these recom mendations to create bedside treatment protocols or standard ized order sets should consult with critical care pharmacists with experience treating the target population.
Members of our guideline panel have created "evidence bulle tins" (1page, laminated cards explaining key recommendations) for distribution to ICUs in partnership with interested provincial organ donation organizations, and leaders in ICU education (bit. ly/dmevidencebulletins). We have also developed adult and pediatric order sets for use by provincial organ donation organ izations and the hospitals that they service (Appendix 1), as well as a family brochure (bit.ly/dmfamilybrochure).
In some cases, a PICO question addressed whether or not to administer a particular medication in a particular circum stance. We made evidencebased recommendations about the appropriateness of the treatment but did not necessarily survey the literature for the best medication or dose from its class (e.g., corticosteroids). In these cases, the panel identified (but did not formally recommend) commonly prescribed medica tions and their usual doses, in order to help clinicians at the bedside.
Canadian Blood Services personnel regularly monitor the lit erature and an update is triggered when there have been any of the following: - New evidence on the existing benefits and harms of interventions; - Changes in outcomes considered important; - Changes in available interventions;
- Changes in evidence that current practice is optimal;
- Changes in values placed on outcomes; or - Changes in resources available for health care.

# Other guidelines
Members of this group performed a systematic review of pub lished organ donor management guidelines 36 to guide the scope of this guideline document. This review of 27 guidelines from 22 countries provided an overview of topics that had been covered by other groups and informed our initial list of potential PICO questions. In contrast to previous guidelines on organ donor management, this guideline was derived using GRADE methodology. For patients Most individuals in this situation would want the recommended course of action and only a small proportion would not.
The majority of individuals in this situation, if fully informed, would choose the suggested course of action, but some would not.

# For clinicians
Most individuals should receive the intervention. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator.
The care needs of individual donors may vary as a result of comorbidities, and the practice of individual clinicians may vary in these circumstances, largely owing to the lack of evidence to address these situations.

# For policymakers
The recommendation can be adapted as policy in most situations
Policymaking will require substantial debate and involvement of various stakeholders.
Modified from Guyatt et al. 46 

# Gaps in knowledge
An important limitation of these guidelines is that organ donor man agement research is predominantly observational in design. Many important clinical questions have not been addressed by RCTs. In addition, our guideline committee identified more PICO questions than we were able to process in this iteration. A list of items for gener ation of potential PICO questions and consideration for future guide lines is included in the full guidance document (Appendix 1).

# Conclusion
The multidisciplinary guideline panel reviewed the literature for 29 PICO questions and generated 1 strong recommendation, 33 con ditional recommendations, and 1 good practice statement as part of a comprehensive and evidencebased clinical practice guideline for organ donor management. It is our hope that this work can optimize use of the scarce resource that donated organs continue to be.