Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Transplantes de Órgãos, Brazilian Research in Critical Care Network, and the General Coordination of the National Transplant System. / Diretrizes brasileiras para o manejo de potenciais doadores de órgãos em morte encefálica. Uma força-tarefa composta por Associação de Medicina Intensiva Brasileira, Associação Brasileira de Transplantes de Órgãos, Brazilian Research in Critical Care Network e Coordenação Geral do Sistema Nacional de Transplantes.

OBJECTIVE: To contribute to updating the recommendations for brain-dead potential organ donor management. METHODS: A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, answered questions related to the following topics were divided into mechanical ventilation, hemodynamics, endocrine-metabolic management, infection, body temperature, blood transfusion, and checklists use. The outcomes considered were cardiac arrests, number of organs removed or transplanted as well as function / survival of transplanted organs. The quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system to classify the recommendations. RESULTS: 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 a good clinical practice. CONCLUSION: Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak.

OBJETIVO: Fornecer recomendações para nortear o manejo clínico do potencial doador em morte encefálica. MÉTODOS: O presente documento foi formulado em dois painéis compostos por uma força tarefa integrada por 27 especialistas de diferentes áreas que responderam a questões dirigidas aos seguintes temas: ventilação mecânica, hemodinâmica, suporte endócrino-metabólico, infecção, temperatura corporal, transfusão sanguínea, e uso de checklists. Os desfechos considerados foram: parada cardíaca, número de órgãos retirados ou transplantados e função/sobrevida dos órgãos transplantados. A qualidade das evidências das recomendações foi avaliada pelo sistema Grading of Recommendations Assessment, Development, and Evaluation. RESULTADOS: Foram geradas 19 recomendações a partir do painel de especialistas. Dessas, 7 foram classificadas como fortes, 11 fracas e uma foi considerada boa prática clínica. CONCLUSÃO: Apesar da concordância entre os membros do painel em relação à maior parte das recomendações, o grau de recomendação é fraco em sua maioria.

Diretrizes brasileiras para o manejo de potenciais doadores de órgãos em morte encefálica. Uma força-tarefa composta por Associação de Medicina Intensiva Brasileira, Associação Brasileira de Transplantes de Órgãos, Brazilian Research in Critical Care Network e Coordenação Geral do Sistema Nacional de Transplantes / Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Transplantes de Órgãos, Brazilian Research in Critical Care Network, and the General Coordination of the National Transplant System

RESUMO Objetivo: Fornecer recomendações para nortear o manejo clínico do potencial doador em morte encefálica. Métodos: O presente documento foi formulado em dois painéis compostos por uma força tarefa integrada por 27 especialistas de diferentes áreas que responderam a questões dirigidas aos seguintes temas: ventilação mecânica, hemodinâmica, suporte endócrino-metabólico, infecção, temperatura corporal, transfusão sanguínea, e uso de checklists. Os desfechos considerados foram: parada cardíaca, número de órgãos retirados ou transplantados e função/sobrevida dos órgãos transplantados. A qualidade das evidências das recomendações foi avaliada pelo sistema Grading of Recommendations Assessment, Development, and Evaluation. Resultados: Foram geradas 19 recomendações a partir do painel de especialistas. Dessas, 7 foram classificadas como fortes, 11 fracas e uma foi considerada boa prática clínica. Conclusão: Apesar da concordância entre os membros do painel em relação à maior parte das recomendações, o grau de recomendação é fraco em sua maioria.

Abstract Objective: To contribute to updating the recommendations for brain-dead potential organ donor management. Methods: A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, answered questions related to the following topics were divided into mechanical ventilation, hemodynamics, endocrine-metabolic management, infection, body temperature, blood transfusion, and checklists use. The outcomes considered were cardiac arrests, number of organs removed or transplanted as well as function / survival of transplanted organs. The quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system to classify the recommendations. Results: 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 a good clinical practice. Conclusion: Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak.

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.

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.

DONORS (Donation Network to Optimise Organ Recovery Study): Study protocol to evaluate the implementation of an evidence-based checklist for brain-dead potential organ donor management in intensive care units, a cluster randomised trial.

INTRODUCTION: There is an increasing demand for multi-organ donors for organ transplantation programmes. This study protocol describes the Donation Network to Optimise Organ Recovery Study, a planned cluster randomised controlled trial that aims to evaluate the effectiveness of the implementation of an evidence-based, goal-directed checklist for brain-dead potential organ donor management in intensive care units (ICUs) in reducing the loss of potential donors due to cardiac arrest. METHODS AND ANALYSIS: The study will include ICUs of at least 60 Brazilian sites with an average of ≥10 annual notifications of valid potential organ donors. Hospitals will be randomly assigned (with a 1:1 allocation ratio) to the intervention group, which will involve the implementation of an evidence-based, goal-directed checklist for potential organ donor maintenance, or the control group, which will maintain the usual care practices of the ICU. Team members from all participating ICUs will receive training on how to conduct family interviews for organ donation. The primary outcome will be loss of potential donors due to cardiac arrest. Secondary outcomes will include the number of actual organ donors and the number of organs recovered per actual donor. ETHICS AND DISSEMINATION: The institutional review board (IRB) of the coordinating centre and of each participating site individually approved the study. We requested a waiver of informed consent for the IRB of each site. Study results will be disseminated to the general medical community through publications in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER: NCT03179020; Pre-results.

Avaliação do tempo de realização do diagnóstico de mortes encefálicas notificadas à Central de Transplantes do Rio Grande do Sul / Evaluation of the time of diagnosis of brain deaths notified to the Center for Transplants of Rio Grande do Sul, Brazil

Objetivos: Avaliar o tempo de realização do diagnóstico de mortes encefálicas notificadas à Central de Transplantes do Rio Grande do Sul e correlacionar o tempo da conclusão desse diagnóstico com os órgãos captados e, consequentemente implantados. Métodos: O estudo incluiu as mortes encefálicas notificadas à Central de Transplantes do Rio Grande do Sul dos doadores efetivos no período de 2003 a 2013. Foram obtidos dados dos doadores (procedência, idade, cor, sexo e causa da morte) e, também, informações sobre o diagnóstico de morte encefálica (data e período do dia em que foi aberto o protocolo, horários do primeiro e segundo teste clínico e horário do exame complementar), bem como os órgãos e tecidos captados e implantados. As comparações de médias entre grupos foram realizadas por meio dos testes t-Student e Anova, ou seus equivalentes não paramétricos Mann-Whitney e Kruskal-Wallis. Resultados: Foram incluídos no estudo 492 doadores efetivos, sendo 275 (55,9%) do sexo masculino. A faixa etária predominante foi a de 40 a 59 anos, com 222 doadores (45,2%). A principal causa de morte foi o acidente vascular encefálico, 276 (56,1%) e o exame complementar mais utilizado foi a angiotomografia, em 177 (36,0%). O rim foi o órgão mais captado, 968 (98,4% da amostra) sendo implantados 94% dos captados; e o coração foi o menos captado, 35 (7,1%), com 100% de implantação. As médias de tempo entre os testes clínicos e a conclusão do diagnóstico de morte encefálica foram de 8,9 e 14,1 horas, respectivamente. Protocolos iniciados à noite e realizados com angiorressonância e eletroencefalograma tiveram um tempo para a conclusão significantemente superior aos demais. Não houve diferença significativa quando correlacionado o tempo de para a conclusão do diagnóstico com os órgãos captados e implantados. Conclusões: O tempo médio total entre os testes clínicos que contemplam o diagnóstico de morte encefálica foi superior ao recomendado pelo Conselho Federal de Medicina. O tempo médio total de realização do diagnóstico de morte encefálica não foi um fator determinante para o número de órgãos captados e implantados.

Aims: To evaluate how long it takes for the diagnosis of brain deaths notified to the Center for Transplants of Rio Grande do Sul, southern Brazil, and to establish a relationship between the time eeded for the diagnosis and the harvest of organs and their transplantation. Methods: The study included brain death notifications to the Center for Transplants of Rio Grande do Sul for donors from 2003 to 2013. Information about the donors (place of origin, age, complexion, sex, and cause of death), about the diagnosis of brain death (date and time of day at which the protocol was created, time of the first and second clinical tests, and time of complementary examination), and about the harvested and transplanted organs and tissues was collected. The means between groups were compared by Student's t test and ANOVA or by their nonparametric counterparts, i.e., Mann-Whitney and Kruskal-Wallis tests. Results: A total of 492 donors were included in the study, among whom 275 (55.9%) were male. There was a predominance of individuals aged 40 to 59 years (222 donors or 45.2%). Stroke was the main cause of death (276 or 56.1%), and CT angiography was the most widely used complementary exam, performed in 177 (36%) individuals. Kidneys were the most frequently harvested organs (968 or 98.4%), being transplanted in 910 (94%) cases. Heart was the least frequently harvested organ (35 or 7.1%), with a transplantation rate of 100%. The average time between the clinical tests and the determination of brain death amounted to 8.9 and 14.1 hours, respectively. Protocols initiated during the night which included magnetic resonance angiography and electroencephalogram presented a higher average time. No significant difference was observed between the time needed for brain death diagnosis and organ harvest and transplantation. Conclusions: The overall average time between clinical tests for the diagnosis of brain death was greater than that recommended by the Brazilian National Medical Council. However, the average time for the diagnosis of brain death was not a determining factor for the number of harvested and transplanted organs.

Transplante hepático / Liver transplantation

Dados sobre transplantes hepáticos realizados no Rio Grande do Sul. (AU)