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Table 1 Summary of recommendations

From: 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

Recommendations Level of evidence Grade of recommendation Practical considerations
Ventilatory support
 1. We recommend using a lung-protective ventilation strategy in all PDs Low Strong Vt between 6 and 8 mL/kg of predicted body weight and PEEP of 8–10-cm H2O
Adjust FiO2 and PEEP to obtain SaO2 > 90%
Perform apnea testing with CPAP
 2. We suggest not using ARM routinely in PDs Very low Weak ARM can be considered if there is refractory hypoxemia in hemodynamically stable PDs
Hemodynamic support
 3. We recommend performing initial volemic expansion in hemodynamically unstable PDs with hypovolemia or responsive to fluids according to fluid responsiveness assessment   Good clinical practice Initial volume expansion with 30 mL/kg of crystalloids
Assess fluid status and responsiveness for additional fluid replacement
Preferably use dynamic parameters
Neutral or negative fluid balance after achieving hemodynamic stability
 4. We recommend administering norepinephrine or dopamine to control blood pressure in PDs who remain hypotensive after volemic expansion Very low Strong Start adrenergic vasopressors to obtain a MAP ≥ 65 mm Hg
Dopamine is the vasopressor of choice when there is bradycardia
Consider the potential arrhythmogenic effect of dopamine, which implies the risk of PD loss due to cardiac arrest
 5. We suggest not using low-dose dopamine for renal protection in PDs Very low Weak Consider the potential arrhythmogenic effect of dopamine, which implies the risk of PD loss due to cardiac arrest
Endocrine and electrolyte management
 6. We recommend combining AVP in PDs receiving norepinephrine or dopamine Low Strong Combine AVP (1 IU bolus + 0.5–2.4 IU/h) with norepinephrine or dopamine
 7. We recommend administering AVP or DDAVP to control polyuria in PDs with diabetes insipidus Low Strong AVP if vasopressors are required.
DDAVP (1–2-µg IV 2–4 h) if vasopressors are not required
 8. We suggest combining low-dose corticosteroids in PDs receiving norepinephrine or dopamine Low Weak Combine 300 mg IV/day in PDs with norepinephrine or dopamine
 9. We suggest not using thyroid hormones routinely in PDs Very low Weak There are no hemodynamic benefits
They can be considered if prolonged management is required
 10. We suggest performing glycemic control in PDs Very low Weak Administer insulin to achieve a glucose level of 140–180 mg/dL
Monitor blood glucose at least every 6 h
 11. We suggest maintaining serum sodium levels < 155 mEq/dL in PDs Very low Weak Correct water deficit with hypotonic fluids
Correct hypovolemia
 12. We recommend maintaining serum potassium levels between 3.5 and 5.5 mEq/L in PDs Very low Strong  
 13. We recommend maintaining serum magnesium levels > 1.6 mEq/L in PDs Very low Strong  
Other aspects
 14. We suggest maintaining nutritional support in PDs if well tolerated Very low Weak  
 15. We recommend using antibiotics in PDs with infection or sepsis Low Strong Maintain appropriate antibiotic therapy in the donor for at least 24 h
Collect cultures from different sites in all donors
 16. We suggest maintaining body temperature above 35 °C in hemodynamically unstable PDs Very low Weak Monitor core temperature
Prevent and treat hypothermia in PDs receiving vasoactive amines
 17. We suggest inducing hypothermia (34–35 °C) in PDs without hemodynamic instability Low Weak Monitor core temperature
Induce hypothermia by applying ice packs in PDs not receiving vasoactive amines
 18. We suggest transfusing packed red blood cells in PDs with hemoglobin levels < 7 g/dL Very low Weak  
 19. We suggest using goal-directed protocols during the management of PDs Very low Weak Monitor care using evidence-based clinical goal-directed checklists
  1. PD: potential donor; Vt: total volume; PEEP: positive-end expiratory pressure; SaO2: arterial oxygen saturation; CPAP: continuous positive airway pressure; ARM: alveolar recruitment maneuver; MAP: mean arterial pressure; AVP: arginine-vasopressin; DDAVP: 1-deamino-8-d-arginine-vasopressin; IV: intravenous