Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System
Authors: Westphal Glauco Adrieno , Robinson Caroline Cabral , Cavalcanti Alexandre Biasi , Gonçalves Anderson Ricardo Roman , Guterres Cátia Moreira , Teixeira Cassiano , Stein Cinara , Franke Cristiano Augusto , da Silva Daiana Barbosa , Pontes Daniela Ferreira Salomão , Nunes Diego Silva Leite , Abdala Edson , Dal-Pizzol Felipe , Bozza Fernando Augusto , Machado Flávia Ribeiro , de Andrade Joel , Cruz Luciane Nascimento , de Azevedo Luciano Cesar Pontes , Machado Miriam Cristine Vahl , Rosa Regis Goulart , Manfro Roberto Ceratti , Nothen Rosana Reis , Lobo Suzana Margareth , Rech Tatiana Helena , Lisboa Thiago , Colpani Verônica , Falavigna Maicon 
Published: December 2020

Abstract
Objective
To contribute to updating the recommendations for brain-dead potential organ donor management.

Method
A 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.

Results
A 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).

Conclusion
Despite 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.