Available via license: CC BY 4.0
Content may be subject to copyright.
Westphaletal. Ann. Intensive Care (2020) 10:169
https://doi.org/10.1186/s13613-020-00787-0
RESEARCH
Brazilian guidelines forthemanagement
ofbrain-dead potential organ donors.
The task force oftheAMIB, ABTO, BRICNet,
andtheGeneral Coordination oftheNational
Transplant System
Glauco Adrieno Westphal1,2,3*, Caroline Cabral Robinson1, Alexandre Biasi Cavalcanti4,
Anderson Ricardo Roman Gonçalves5,6, Cátia Moreira Guterres1, Cassiano Teixeira7,8, Cinara Stein1,
Cristiano Augusto Franke7,9, Daiana Barbosa da Silva1, Daniela Ferreira Salomão Pontes10,
Diego Silva Leite Nunes10, Edson Abdala11, Felipe Dal‑Pizzol12,13, Fernando Augusto Bozza14,15,
Flávia Ribeiro Machado16, Joel de Andrade17, Luciane Nascimento Cruz1, Luciano Cesar Pontes de Azevedo18,
Miriam Cristine Vahl Machado3, Regis Goulart Rosa1, Roberto Ceratti Manfro7,19, Rosana Reis Nothen19,
Suzana Margareth Lobo20, Tatiana Helena Rech7, Thiago Lisboa7, Verônica Colpani1 and Maicon Falavigna1,21,22
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 epidemi‑
ologists, 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/sur‑
vival. 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,
© The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material
in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material
is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the
permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco
mmons .org/licen ses/by/4.0/.
Open Access
*Correspondence: glauco.ww@gmail.com.br
1 Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre,
RS 90035000, Brazil
Full list of author information is available at the end of the article
Page 2 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
Introduction
Organ donation for transplantation is a complex process
led by several health care professionals responsible for a
sequence of actions and procedures that begin with iden-
tifying a potential organ donor and end with organ pro-
curement surgery and distribution. e progress of this
process is essential to increase the deceased-donor pool,
and to decrease the growing disparity between the num-
ber of patients on transplant waiting lists and the avail-
ability of organs [1, 2].
e organ donation process includes the identification
of the potential donor, diagnosis of brain death, family
support and interview, evaluation of donor eligibility cri-
teria, clinical management of the potential organ donor,
and organ procurement and distribution [2, 3]. Given
the marked clinical instability that occurs in patients
who progress to brain death, the application of poten-
tial donor-management strategies aiming at hemody-
namic stabilization is crucial to avoid loss of organs due
to hypoperfusion or loss of donors due to cardiac arrest.
Also, the control of ventilatory support, body tempera-
ture, and endocrine-metabolic functions contributes to
improving the quality of organs and clinical outcomes in
transplant recipients [1, 2, 4, 5].
Despite the lack of evidence on some aspects of the
clinical management of potential organ donors, the
recommendations presented in this guideline intend
to promote a general approach to mitigate the dis-
parity between supply and demand of organs for
transplantation.
Objective
To provide recommendations to guide the clinical man-
agement of brain-dead potential organ donors aiming to
reduce the rate of cardiac arrest of the potential donor
and to improve organ viability for transplantation.
Method
e present document provides a partial update on the
2011 Brazilian Guidelines for Management of Adult
Potential Multiple-Organ Deceased Donors [6–8].
e working group consisted of physicians, nurses,
pharmacists, physical therapists, epidemiologists, meth-
odologists, and transplant system managers. e contri-
butions of each participant are shown in Additional file1,
and the respective conflict-of-interest disclosures are
shown in Additional file2.
e target audience of this guideline is health care pro-
fessionals, especially physicians and nursing staff work-
ing in adult ICUs and emergency departments, who are
involved in the care of adult individuals with known or
suspected brain death.
e clinical issues addressed by the guideline were
defined by coordinators of the working group and the
methodologists in a face-to-face meeting held in March
2016, after reviewing the recommendations of the 2011
Brazilian Guidelines for Management of Adult Potential
Multiple-Organ Deceased Donors [6–8]. e issues were
prioritized according to the perception of their impact on
medical management and variability in clinical practice
and divided into the following major topics: (1) ventila-
tory support; (2) hemodynamic support; (3) endocrine,
metabolic and nutritional management; (4) specific
aspects that include infection and sepsis, red blood cell
transfusion, and body temperature control; and (5) goal-
directed therapy. For each clinical issue, operational
questions were developed and framed using the PICO
(population-intervention-comparison-outcome) format.
e population of interest consists of potential organ
donors with known or suspected brain death [3], hereaf-
ter referred to as potential donors. e outcomes consid-
ered for decision-making were cardiac arrest, the number
of organs recovered or transplanted per donor, and graft
function or graft survival.
For each clinical issue, rapid systematic reviews [9, 10]
were conducted using the following search strategy: (1)
Review of the reference lists of Brazilian guidelines [6–8]
and the Society of Critical Care Medicine (SCCM) [11]
statement on the management of the potential organ
donor; (2) Review of related topics in the DynaMed and
UpToDate databases; and (3) PubMed search focusing
on systematic reviews and clinical trials published until
October 2016 and until January 2017. Quality of evidence
was assessed using the Grading of Recommendations
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 recommenda‑
tion 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.
Keywords: Guidelines, Organ donation, Intensive care, Brain death, GRADE
Page 3 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
Assessment, Development, and Evaluation (GRADE) sys-
tem [12].
e recommendations were prepared and submitted to
two face-to-face expert panels held in November 2016,
and February 2017. For each recommendation, the direc-
tion of the course of action was discussed (whether to
perform or not to perform the proposed action), and the
strength of the recommendation was classified as strong
or weak according to the GRADE system [12]. After the
last panel meeting, a new systematic search covering the
period from October 2016 to May 2020 was carried out
to identify new evidence that could potentially modify
the recommendations. From June to July 2020, a Delphi
process was performed with the panelists to present the
results of the literature update and review the direction
and strength of 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 as good clinical practice.
Table1 shows a summary of the recommendations. Fig-
ure1 presents graphically the flow of the recommenda-
tions along the clinical management. Additional file 3
provides a checklist with the main recommendations
with a positive direction of action to assist in bedside
monitoring of clinical goals related to the recommenda-
tions and in the application of the management strategies.
Ventilatory support
1. We recommend using a lung-protective ventilation
strategy in all potential donors (low level of evidence,
strong recommendation).
Summary of evidence In potential donors, an initially
normal or near-normal lung function (PaO2/FiO2 ≥ 300)
may deteriorate due to common complications in criti-
cal patients, such as pulmonary contusion, lung injury
following blood transfusion, pneumonia, atelectasis,
and mechanical ventilation-related iatrogenic injuries
[13–18]. In addition, approximately 30–45% of poten-
tial donors develop acute respiratory distress syndrome
(ARDS; PaO2/FiO2 < 300), and only 15–20% of the lungs
are suitable for transplantation at the end of the procure-
ment process [13, 15, 17]. e lung-protective ventilation
strategy in potential donors with normal lungs and the
apnea testing performed with continuous positive airway
pressure (CPAP) have been associated with an increase in
eligibility for lung donation [18–20].
Remarks e protective ventilation strategy for healthy
lungs consists of the combination of a tidal volume of
6–8 mL/kg and PEEP of 8–10-cm H2O. To promote
adequate blood oxygenation, FiO2 and PEEP must be
adjusted to obtain a SaO2 > 90%. To avoid atelectasis,
the apnea test with 10cm H2O CPAP can be performed
using a closed-circuit system in potential donors with
preserved lungs who are candidates for lung procure-
ment, or even when hypoxemic respiratory failure is
present. Also, the same procedure can be considered on
those who have failed the test due to hypoxemia after
disconnection.
2. We suggest not using alveolar recruitment maneu-
vers routinely in potential donors (very low level of
evidence, weak recommendation).
Summary of evidence Although alveolar recruitment
maneuvers have been suggested for the ventilatory
management of organ donors with lung injury (PaO2/
FiO2 < 300) [13–16, 18, 20], and these maneuvers could
reduce hypoxemia after apnea testing, contributing to
increasing the viability of pulmonary grafts [14–18, 20],
a randomized clinical trial showed unfavorable outcomes
in critically ill patients [21]. Besides, no randomized stud-
ies have demonstrated their efficacy in the population of
potential donors.
Remarks Performing alveolar recruitment maneuvers
in hemodynamically stable potential donors is probably
feasible in units with experience in the management of
ARDS. In cases of hypoxemia refractory to the lung-pro-
tective ventilation strategy, however, alveolar recruitment
maneuvers should not be performed routinely. eir use
is not indicated in hemodynamically unstable potential
donors.
Hemodynamic support
Volemic expansion andvasopressors
3. We recommend performing initial volemic expan-
sion 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 expan-
sion (very low level of evidence, strong recommenda-
tion).
Summary of evidence Potential donor hypotension is
associated with a higher incidence of postoperative liver
graft dysfunction and longer hospital stay in liver trans-
plant recipients [22, 23]. Targeting a mean arterial pres-
sure (MAP) ≥ 65mm Hg has also been associated with
reduced occurrence of cardiac arrest in potential donors
Page 4 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
Table 1 Summary ofrecommendations
Recommendations Level ofevidence Grade ofrecommendation Practical considerations
Ventilatory support
1. We recommend using a lung‑protective venti‑
lation 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 hypox‑
emia 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 crystal‑
loids
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 norepineph‑
rine 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 receiv‑
ing norepinephrine or dopamine
Low Strong Combine AVP (1 IU bolus + 0.5–2.4 IU/h) with norepi‑
nephrine 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 corticos‑
teroids 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 potas‑
sium levels between 3.5 and 5.5 mEq/L in PDs
Very low Strong
13. We recommend maintaining serum magne‑
sium 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 dur‑
ing the management of PDs
Very low Weak Monitor care using evidence‑based clinical goal‑
directed checklists
Page 5 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
[22, 24]. Intravascular volume expansion guided by ven-
tricular filling pressures or respiratory pulse pressure
variation (PPV) in hemodynamically unstable potential
donors is associated with faster recovery of renal graft
function and reduced circulating levels of inflammatory
cytokines [22, 25]. A randomized trial detected no differ-
ence between usual fluid management or fluid manage-
ment directed by a PPV and cardiac index. On the other
hand, there was a trend toward an increase in the number
of organs transplanted per donor among unstable poten-
tial donors responsive to fluids (p = 0.059) [26].
Conversely, avoiding fluid overload after the initial vol-
ume resuscitation to stabilize blood pressure seems to
be beneficial. is approach is associated with a greater
number of organs transplanted per donor and a greater
number of lungs transplanted without reducing the num-
ber of other donated organs or impairing survival in the
heart, liver, pancreas, or kidney transplant recipients [19,
27–29].
If hypotension persists after adequate volume resusci-
tation, adrenergic vasopressors should be used to achieve
adequate blood-pressure levels [30]. ere is no dif-
ference in clinical outcomes in studies comparing nor-
epinephrine and dopamine [31–33]. Disruption of vagal
activity secondary to brain death may result in atropine-
refractory bradycardia. In these cases, adrenergic drugs
Table 1 (continued)
PD: potential donor; Vt: total volume; PEEP: positive-end expiratory pressure; SaO2: ar terial 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
Fig. 1 Flow of the recommendations
Page 6 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
as isoproterenol, epinephrine, and dopamine have been
suggested as positive chronotropic agents to treat brad-
ycardia in potential donors. Considering the predomi-
nance of noradrenaline action on alpha-1 receptors, its
infusion usually occurs without significant increase in
heart rate. Hence, dopamine or epinephrine may be more
convenient for the treatment of hypotension due to a
positive chronotropic effect [6, 34, 35].
Remarks Obtaining an MAP ≥ 65mm Hg as a blood-
pressure target contributes to the perfusion of organs
that are intended to be preserved for transplantation
[22–24]. Hypovolemia is very frequent in potential organ
donors and should be considered when hypotension is
present. e initial infusion of crystalloids (e.g., 30mL/
kg) in potential donors who are hypovolemic or respon-
sive to fluids (when any fluid responsiveness assessment
parameter is already available) contributes to blood-pres-
sure control by improving tissue perfusion [24–26].
Conversely, fluid overload should be avoided [19,
27–29]. Assessment of fluid responsiveness with static
variables (e.g., central venous pressure—CVP) and/or
dynamic parameters (e.g., PPV) can be used to guide
volume replacement, helping to prevent fluid overload.
Dynamic parameters can more accurately discriminate
between responsive and unresponsive individuals [30–
38]. Once hemodynamic stability is achieved, strategies
aimed at neutral fluid balance may be more beneficial
[19, 27–29].
If the blood-pressure target is not achieved with the ini-
tial volume expansion, norepinephrine or dopamine infu-
sion should be started immediately. e use of dopamine
is likely advantageous for cases of bradycardia with signs
of low cardiac output [6, 34, 35], but the arrhythmogenic
potential of dopamine should be considered [39].
5. We suggest not using low-dose dopamine for renal
protection in potential donors (very low level of evi-
dence, weak recommendation).
Summary of evidence A cohort study of 93 heart trans-
plant recipients showed that pretreatment with low-dose
dopamine (4μg/kg/min) in heart donors was associated
with higher graft survival 3 years after transplantation
(87.0 vs. 67.8%, p < 0.03) [40]. A randomized-controlled
trial of 264 organ donors reported that the administra-
tion of low-dose dopamine reduced the need for hemodi-
alysis in recipients (OR 0.54; 95% CI 0.35–0.83), but with
no benefits for kidney graft survival after 3 years [41].
In the 5-year follow-up analysis of 487 renal transplant
recipients from the same trial, the researchers failed to
show a significant advantage of dopamine administration
in potential donors to long-term kidney graft survival,
although time of dopamine infusion and graft failure
were exposure-related (HR 0.96; 95% CI 0.92–1.00, per
hour) [42]. e same group reported that low-dose dopa-
mine did not negatively affect the short- or long-term
outcomes after liver transplants [43].
Remarks Although the administration of low-dose
dopamine in potential donors reduces the need for multi-
ple dialysis sessions, the long-term benefits for heart and
kidney graft survival are unclear. e panel considered
the potential arrhythmogenic effect of dopamine, which
may imply a greater risk of loss of potential donors due to
cardiac arrest before organ procurement.
Endocrine andelectrolyte 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).
Summary of evidence e use of AVP in brain-dead
potential donors contributes to reducing the need for
adrenergic vasopressors and is associated with a lower
incidence of cardiovascular deterioration and cardiac
arrest [44–48], in addition to contributing to the control
of plasma hyperosmolarity [46]. AVP infusion allows, in
some cases, complete discontinuation of adrenergic vaso-
pressors without causing adverse effects on the function
of organs transplanted [48, 49]. Finally, AVP infusion
seems to be associated with a greater number of donated
organs and a lower rate of graft refusal due to organ dys-
function [45].
Remarks e administration of an initial 1 IU AVP
bolus followed by infusion of 0.5IU/h to 2.4 UI/h helps
to maintain blood pressure in potential donors requiring
vasopressors, and contributes to the control of polyuria
and normovolemia in the presence of diabetes insipidus
[44–46, 48, 49]. AVP should be started at the same time
of adrenergic vasopressor infusion.
7. We recommend administering AVP or 1-deam-
ino-8--arginine vasopressin (DDAVP) to control
polyuria in potential donors with diabetes insipidus
(low level of evidence, strong recommendation).
Summary of evidence e analysis of the database of a
randomized clinical trial that evaluated 487 renal graft
recipients showed better control of daily urine output
(p < 0.001) and a lower need for fluids in the DDAVP
group (p < 0.001). DDAVP was associated with improved
renal graft survival (85.4% vs. 73.6%, p = 0.003) af ter
2years, with no differences in acute rejections (OR 1.32;
Page 7 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
95% CI 0.70–2.49) or delayed graft function (OR 0.97;
95% CI 0.57–1.65) [50].
Remarks DDAVP acts exclusively on V2 receptors and
is indicated to control polyuria (urine output > 4 mL/
kg/h) in potential donors with diabetes insipidus who
maintain adequate blood pressure without adrenergic
vasopressors. AVP is preferred to control polyuria in
potential donors with diabetes insipidus who need adren-
ergic vasopressors. e combination of AVP and DDAVP
may be considered in refractory cases [51]. Although the
intranasal route is feasible, DDAVP should preferably be
administered intravenously, at a dose of 1–2µg every
2–4h [8, 13, 15], until a urine output < 4 mL/kg/h has
been achieved [50–53].
8. We suggest using low-dose corticosteroids in poten-
tial donors receiving norepinephrine or dopamine to
control blood pressure (low level of evidence, weak
recommendation).
Summary of evidence A small retrospective study
reported that administration of 15-mg/kg methylpred-
nisolone was associated with higher PaO2/FiO2 values
(p = 0.01) and a greater number of lungs transplanted
(p < 0.01) [54]. Conversely, a before-and-after study
comparing 15-mg/kg methylprednisolone with 300-mg
hydrocortisone found no difference in the oxygenation
and hemodynamic stability of the potential donor or in
the number of organs transplanted [55]. A recent small
randomized-controlled trial showed that a single dose
of 15 mg/kg/day of methylprednisolone administered
to the potential organ donor may negatively affect the
graft function by increasing the antigenicity of the kid-
neys before transplantation. is negative effect was not
noticed among brain-dead donors who received 15mg/
kg/day of methylprednisolone followed by 100mg every
2 h until organ harvesting [56]. Eleven randomized-
controlled trials analyzed in a systematic review did not
support the use of high-dose corticosteroids in the man-
agement of potential donors [57]. On the other hand, a
randomized multicenter cluster study including 259
individuals compared the administration of low-dose
hydrocortisone (300 mg/day) with no corticosteroids.
e doses (p = 0.03) and duration of infusion (p < 0.001)
of vasopressors were lower in the intervention group, and
the complete vasopressor withdrawal was 4.7 times more
frequent in the corticosteroid group [58].
Remarks Despite conflicting evidence, the use of corti-
costeroids is of low cost and a low risk to potential donors
and may have a positive effect on hemodynamic out-
comes; therefore, their use is indicated in these patients.
Current evidence does not suggest ventilatory or hemo-
dynamic benefits associated with corticosteroid therapy
at high doses compared with low doses (i.e., 100mg every
8h). Higher doses should be avoided.
9. We suggest not using thyroid hormones routinely in
potential donors (very low level of evidence, weak
recommendation).
Summary of evidence Administration of thyroid hor-
mones in potential donors did not add any benefit, such
as a reduction in vasopressor use, an increase in cardiac
index, or an increase in organ procurement for trans-
plantation [59–65]. Observational studies had suggested
an increase in heart procurement, which was not con-
firmed in randomized clinical trials [66, 67], even in
brain-dead organ donors with hemodynamic instability
and/or impaired cardiac function [68, 69].
Remarks Brain death is associated with a drop in circu-
lating thyroid hormone levels, which could contribute to
hemodynamic instability; however, there is no evidence
to support the use of thyroid hormones in potential
donors, given their costs and risks.
10. We suggest performing glycemic control in poten-
tial donors (very low level of evidence, weak rec-
ommendation).
Summary of evidence Four observational studies eval-
uated the effect of potential donor hyperglycemia on
post-transplant pancreatic function [70–73]. One study
showed a correlation between donor blood glucose
immediately before organ retrieval and HbA1C 1 year
after transplantation [73], and another study found an
association between hyperglycemia and graft loss (HR
1.4; p = 0.03) [74]. Two studies showed no association
between potential donor blood glucose and post-trans-
plant pancreatic graft function [70–72]. One obser-
vational study found an association between glycemic
control and creatinine of the potential donor before
organ retrieval [75]. Conversely, there is no evidence that
hyperglycemia is associated with liver graft dysfunction
[76]. A study of 1611 potential donors reported that a
glucose level < 180mg/dL was an independent predictor
of four or more organs transplanted per donor (OR 1.35;
95% CI 1.01–1.82) [77]. A set of potential donor care
measures, including glycemic control, was associated
with achieving ≥ 3 organs transplanted per donor (OR
1.9; 95% CI 1.35–2.68), but it was not possible to assess
the isolated effect of glycemic control [78].
Remarks Very-low-quality evidence suggests that a
glucose level < 180 mg/dL is associated with a greater
number of organs transplanted. Blood glucose should be
monitored in all potential donors at least every 6h, tar-
geting levels of 140–180mg/dL, and intravenous insulin
infusion can be used to this end.
Page 8 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
Electrolytes
11. We suggest maintaining serum sodium levels below
155mEq/dL in potential donors (very low level of
evidence, weak recommendation).
Summary of evidence. Five descriptive observational
studies were identified (n = 5733), which evaluated
only graft viability/function. In four of these studies
(n = 5545), there was no negative effect of donor hyper-
natremia above 155mEq/L on liver or heart graft func-
tion [79–82]. In only one study (n = 188), hypernatremia
was associated with more cases of early graft loss [83].
Some authors have suggested that deceased-donor
hypernatremia may be a factor for worse prognosis of
graft function, but these findings have not been univer-
sally confirmed [79–85]. Changes in natremia may reflect
inadequate volume management, especially in the pres-
ence of diabetes insipidus, one of the reasons for its cor-
rection [11].
Remarks Hypernatremia is often associated with hypo-
volemia, and should be controlled with volume expan-
sion, replacement of hypotonic fluids, and control of
polyuria with AVP or DDAVP. Serum sodium should be
monitored, targeting levels < 155mg/dL.
12. We recommend maintaining serum potassium lev-
els between 3.5 and 5.5mEq/L in potential donors
(very low level of evidence, strong recommenda-
tion).
Summary of evidence ere are no studies that directly
evaluate the effect of hyper- or hypokalemia in poten-
tial donors. A comparison of potassium levels in ICU
patients showed that hyperkalemia was more common
in patients who died (9.2% vs. 0.9%, p < 0.001) and that
serum potassium concentration could be a predictor of
death in critically ill patients [86].
Remarks Despite the absence of studies directly evalu-
ating the effects of potential donor serum potassium
levels, potassium is a determining factor in the resting
potential of electrically sensitive cells. Changes in potas-
sium levels are related to cardiac arrhythmias and may
compromise the management of potential donors. Potas-
sium levels should be monitored, and usual correction
measures should be implemented, targeting serum levels
between 3.5 and 5.5mEq/L.
13. We recommend maintaining serum magnesium
levels above 1.6 mEq/L in potential donors (very
low level of evidence, strong recommendation).
Summary of evidence Studies on the influence of serum
magnesium levels were found in critically ill patients,
but none in potential donors [87–92]. Two observa-
tional studies and one randomized study identified
an association between hypomagnesemia and higher
mortality in critically ill patients [87, 88, 91], in addi-
tion to a greater likelihood of QT interval prolongation
(OR 42.8; 95% CI 14.5–126.2) [88]. is association of
hypomagnesemia with mortality was reinforced in a sys-
tematic review [89]. In addition to being arrhythmogenic,
hypomagnesemia appears to be associated with non-
recovery of renal function in patients with acute kidney
injury (70% vs. 31%, p = 0.003) [92].
Remarks Hypomagnesemia is associated with cardiac
arrhythmias and worse prognosis in critically ill patients,
with no direct evidence in brain-dead potential donors.
However, this is a low-cost procedure, and in the ICU
setting, routine monitoring until normalization of mag-
nesium levels is a common practice, which may be ben-
eficial for potential donors. Magnesium levels should be
monitored, and magnesium sulfate should be adminis-
tered, as usual, targeting serum levels above 1.6mEq/L.
Other aspects ofpotential donor management
Nutritional support
14. We suggest maintaining nutritional support in
potential donors if well tolerated (very low level of
evidence, weak recommendation).
Summary of evidence Although there is no evidence on
nutritional support, different guidelines recommend con-
tinuing nutritional support of the donor in the absence
of contraindications [7, 9, 51]. Possible benefits include
increased liver glycogen reserves, which could posi-
tively influence the liver graft [93, 94], and maintenance
of intestinal mucosal trophism, which could reduce the
potential for bacterial translocation.
Remarks For brain-dead individuals requiring ICU
management for prolonged periods (e.g., brain-dead
pregnant women; prolongation of the diagnostic pro-
cess or the family decision for donation), it is reasonable
that energy expenditure should be estimated or meas-
ured [95], considering that baseline energy expenditure
is 15–30% lower in brain-dead individuals than in other
critically ill patients [96]. us, in individuals already
receiving full nutritional support, energy intake may be
reduced once brain death is established. A minimum
energy intake (e.g., 500 kcal) could be considered in
potential donors who had not been on enteral feeding
before brain death was diagnosed, taking into account its
potential benefit in the maintenance of intestinal mucosal
trophism. However, it does not seem appropriate to start
enteral feeding when the organs are likely to be har-
vested within a short period or in the presence of any of
the usual contraindications to initiate/maintain enteral
feeding (e.g., gastrointestinal tract obstruction, ileus,
Page 9 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
vomiting/aspiration of gastric contents, severe hemody-
namic instability, and high doses of vasopressors).
Infection andsepsis
15. We recommend using antibiotics in potential
donors with infection or sepsis (low level of evi-
dence, strong recommendation).
Summary of evidence Different observational studies
evaluated the transmission of bacterial infection in organ
donors with culture-proven infection. e most com-
monly observed microorganisms were Staphylococcus
aureus, Streptococcus sp., Klebsiella sp., and Acinetobac-
ter baumannii. Bacterial transmission is rarely observed
[97–104], provided that donors with evidence of infec-
tion receive appropriate antibiotic therapy [97–102, 105,
106]. e duration of donor antibiotic therapy ranged
from 24 to 96h in different studies [97, 99, 102, 105].
Also, different authors have reported maintaining the
same antibiotics administered to the donors in the trans-
plant recipients, for periods ranging from 7 to 14days
[98, 100, 105, 106]. e presence of donor infection had
no impact on the survival of grafts or transplant recipi-
ents [97–102, 105, 106].
Remarks e risk of transmission of bacterial infection
from organ donors to recipients is low, and donor infec-
tion does not appear to negatively affect outcomes. e
risks are lower with appropriate antibiotic therapy in the
donor for at least 24h, followed by maintenance of the
antibiotic in the recipient for 7–14days [97–102, 105,
106]. Some donors have subclinical bacteremia at the
time of organ procurement; therefore, cultures should be
collected from blood and different sites in all donors, and
the recipient antibiotic therapy should be directed by the
results of culture [99, 107–110].
Body temperature control
16. We suggest maintaining body temperature above
35 °C in hemodynamically unstable potential
donors (very low level of evidence, weak recom-
mendation).
17. We suggest inducing moderate hypothermia (34–
35°C) in potential donors without hemodynamic
instability (low level of evidence, weak recommen-
dation).
Summary of evidence Delayed renal graft function
was evaluated in a randomized-controlled trial that
compared hypothermia (34–35°C) versus usual man-
agement (36.5–37.5°C) in 370 potential donors without
hemodynamic instability. e main result was a reduc-
tion in delayed renal graft function among recipients
(OR 0.62; 95% CI 0.43–0.92). ere was no differ-
ence in the number of organs transplanted per donor,
adverse events, or cardiac arrest [111]. Two retrospec-
tive cohort studies nested in the randomized dopamine
trial demonstrated that spontaneous donor hypother-
mia was associated with lower creatinine levels before
organ procurement without effect on kidney graft
survival [112], and with an unfavorable clinical course
after heart transplant [113]. In a clinical population of
post-cardiac arrest patients, i.e., patients at increased
risk of hemodynamic instability, a meta-analysis of five
clinical trials found a higher risk of recurrent arrest in
patients with induced hypothermia (< 35°C) in prehos-
pital management (RR 1.23; 95% CI 1.02–1.48) [114].
Remarks Hypothermia is a low-cost intervention
[115] associated with better renal graft function, but it
can increase the risk of cardiac arrest in the potential
donor [111, 114]. e risk appears to be low in hemo-
dynamically stable potential donors, in whom the use
of hypothermia can be justified by improved graft via-
bility. In the presence of hemodynamic instability [111],
normothermia (> 35°C) should be maintained in poten-
tial donors to reduce the risk of cardiac arrest [114].
Induction of moderate hypothermia (34–35°C) is con-
sidered a simple (application of ice packs) and inex-
pensive approach, but it is important to monitor core
temperature, which is not available in all ICUs.
Red blood cell transfusion
18. We suggest transfusing packed red blood cells in
potential donors with hemoglobin levels < 7 g/dL
(very low level of evidence, weak recommenda-
tion).
Summary of evidence e systematic literature search
identified 1 descriptive observational study that evalu-
ated function in 1884 renal grafts from 1006 brain-dead
donors. Among donors, 52% received blood transfu-
sion. Renal grafts from transfused donors had a lower
rate of delayed graft function than those from non-
transfused donors (26% vs. 34%, p < 0.001). e criteria
defining the need for blood transfusion were not identi-
fied [116].
Remarks Anemia can compromise oxygen transport
and delivery to the organs that are intended to be pre-
served for transplantation. However, we are unaware of
the hemoglobin concentration necessary to contribute
to adequate oxygen transport and delivery in potential
donors. Considering the high cost and frequent shortage
of blood products for transfusion, the decision to trans-
fuse should not differ from the usual practice in other
critically ill patients.
Page 10 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
Goal‑directed protocols
19. We suggest using a goal-directed protocol during
the management of potential donors (very low level
of evidence, weak recommendation).
Summary of evidence Although there is no consistent
evidence about an individual treatment that will improve
the number and quality of donated organs [117], obser-
vational studies have reported that combining different
treatments through the application of a potential donor-
management protocol is associated with a higher organ
yield for transplantation [24, 78, 118–124], lower inci-
dence of delayed renal graft function [111], greater eligi-
bility for lung donation [19, 28], and lower incidence of
donor losses due to cardiac arrest [19, 24, 28, 119, 120].
In general, the outcomes are associated with the number
of goals achieved during potential donor management,
including ventilatory, hemodynamic, and endocrine-
metabolic management goals [24, 78, 121–123]. In seven
studies, the use of a checklist helped implement the goal-
directed protocols and may have positively influenced the
results [19, 28, 78, 121, 124–126].
Remarks e application of a potential donor-manage-
ment protocol guided by a clinical goal-directed checklist
may contribute to increasing the number of organs trans-
planted per donor, influence graft function, and reduce
donor losses due to cardiac arrest.
General considerations andfuture directions
e present guideline aimed to provide parameters to
optimize the clinical management of potential donors
based on the available evidence, aiming to improve the
quality of organs for transplantation and to reduce donor
losses. However, it is well known that it may take years
for a large-scale translation of the best scientific evidence
into effective practice. us, establishing clinical proto-
cols can help to reduce the time required to incorporate
best practices. e use of a goal-directed checklist can
play an important role in the adjustment of approaches
and adherence to the best evidence in complex proce-
dures [127–130].
is guideline evaluated a broad volume of treatments
and we performed rigorous PICO-driven research to
provide the recommendations based on standardized
rapid review methods [9, 10]. Potential limitations are
the low or very low certainty in the evidence identified
for many of the questions, and indirect evidence that did
not change after the systematic review update. However,
management recommendations are consistent with simi-
lar documents recently published [11, 131, 132].
Several challenges regarding ethical, infrastructure, and
operational issues are faced while planning and conduct-
ing studies that involve potential organ donors, which
results in few randomized clinical trials [133]. e scar-
city of studies with such methodological strength implies
uncertainties about some interventions such as low-dose
dopamine and moderate hypothermia, which, despite
appearing to be related to renal graft benefit, may result
in cardiac arrhythmias and hemodynamic instability.
In this context, developing clinical trials in this field of
medical knowledge may be helpful to understand some
important aspects in the management of the potential
organ donor.
Some observational studies have reported that the
application of a checklist to guide the management of
brain-dead potential donors may help to reduce the rate
of cardiac arrest in potential donors and increase the
number of organs recovered per donor [24, 78, 119, 121,
122, 124, 126, 134, 135]. In this context, we used the main
recommendations of the present guideline to develop an
evidence-based clinical goal-directed checklist (Addi-
tional file 3) with the purpose of providing transplant
coordinators and ICU professionals with essential infor-
mation to optimize the care of potential donors.
However, because the available studies highlighting
the role of potential donor-management checklists are
observational, there is insufficient evidence to support
the systematic use of checklists in the management of
potential donors. erefore, we proposed the Donation
Network to Optimize Organ Recovery Study (DONORS;
NCT03179020), which is a parallel cluster randomized-
controlled multicenter trial that aims to test the effec-
tiveness of the implementation of a checklist containing
goals and recommendations of care in reducing organ
donor losses due to cardiac arrest and increasing the
number of organs recovered per donor [136].
e implementation of the checklist should be pre-
ceded by the appropriate training of intensive care teams
and transplant coordinators. We suggest applying the
checklist at the bedside immediately after the first clinical
examination for the diagnosis of brain death, repeating
the application, ideally, every 6 h until organ procure-
ment for transplantation. We also suggest that a mem-
ber of the transplant coordination office or a designated
professional of the ICU or emergency department applies
the checklist at the bedside. e same individual will also
be responsible for personally prompting the physician in
charge to modify the clinical management if any inappro-
priate aspect of care, according to the checklist, is noted.
Page 11 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
Supplementary information
Supplementary information accompanies this paper at https ://doi.
org/10.1186/s1361 3‑020‑00787 ‑0.
Additional le1. Working group and contributions of each participant.
Additional le2. Declaration of competing interests.
Additional le3. Checklist for clinical management of brain‑dead poten‑
tial organ donor.
Acknowledgements
The authors would like to thank the Brazilian Ministry of Health and the Gen‑
eral Coordination Office of the National Transplant System (CGSNT), as well as
Moinhos de Vento Hospital, the Brazilian Association of Organ Transplantation
(ABTO), the Brazilian Association of Intensive Care Medicine (AMIB) Committee
for Organ Donation for Transplant, and the Brazilian Research in Intensive Care
Network (BRICNet) for their support.
Authors’ contributions
All authors, except for AR, DFSP, FDP, RCM, and RRN, participated in at least one
of the expert panels. All authors read and approved the final manuscript. The
detailed contribution of each author is presented in Additional file 1.
Funding
This guideline was funded by the Brazilian Ministry of Health through the
Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de
Saúde (PROADI‑SUS). The funding body has no role in the coordination of the
guideline.
Availability of data and materials
All relevant data are within the paper and its additional files.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The competing interests of each author are presented in Additional file 2.
Author details
1 Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre,
RS 90035000, Brazil. 2 Hospital Municipal São José (HMSJ), Joinville, SC, Brazil.
3 Centro Hospitalar Unimed, Joinville, SC, Brazil. 4 Hospital do Coração (HCor),
R. Desembargador Eliseu Guilherme, 147, São Paulo, SP 04004030, Brazil. 5 Uni‑
versidade da Região de Joinville (UNIVILLE), R. Paulo Malschitzki, 10, Joinville,
SC 89219710, Brazil. 6 Clínica de Nefrologia de Joinville, R. Plácido Gomes, 370,
Joinville, SC 89202‑050, Brazil. 7 Hospital de Clínicas de Porto Alegre (HCPA),
R. Ramiro Barcelos, 2350, Porto Alegre, RS 90035007, Brazil. 8 Universidade
Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite, 245,
Porto Alegre, RS 90050‑170, Brazil. 9 Hospital de Pronto de Socorro (HPS), Porto
Alegre, RS, Brazil. 10 General Coordination Office of the National Transplant
System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício
Sede, Brasília, DF 70058900, Brazil. 11 Faculdade de Medicina, Universidade
de São Paulo (USP), Av. Dr, Arnaldo 455, Sala 3206, São Paulo, SP 01246903,
Brazil. 12 Universidade do Extremo Sul Catarinense (UNESC), Av. Universitária,
1105, Criciúma, SC 88806000, Brazil. 13 Intensive Care Unit, Hospital São José,
R. Cel. Pedro Benedet, 630, Criciúma, SC 88801‑250, Brazil. 14 National Institute
of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Av.
Brasil, 4365, Rio de Janeiro, RJ 21040360, Brazil. 15 Instituto D’Or de Pesquisa
e Ensino (IDOR), R. Diniz Cordeiro, 30, Rio de Janeiro, RJ 22281100, Brazil.
16 Hospital São Paulo (HU), Universidade Federal de São Paulo (UNIFESP), R.
Napoleão de Barros 737, São Paulo, SP 04024002, Brazil. 17 Organização de
Procura de Órgãos e Tecidos de Santa Catarina (OPO/SC), Rua Esteves Júnior,
390, Florianópolis, SC 88015130, Brazil. 18 Hospital Sírio‑Libanês, R. Dona Adma
Jafet, 115, São Paulo, SP, Brazil. 19 Universidade Federal do Rio Grande do Sul
(UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS 90035007, Brazil. 20 Facul‑
dade de Medicina de São José do Rio Preto, Av Faria Lima, 5544, São José
do Rio Preto, SP 15090000, Brazil. 21 National Institute for Health Technology
Assessment, UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS 90035903,
Brazil. 22 Department of Health Research Methods, Evidence, and Impact (HEI),
McMaster University, 1280 Main St W, Hamilton, ON, Canada.
Received: 3 August 2020 Accepted: 1 December 2020
References
1. Tullius SG, Rabb H. Improving the supply and quality of deceased‑
donor organs for transplantation. N Engl J Med. 2018;378:1920–9. https
://doi.org/10.1056/NEJMr a1507 080.
2. The Madrid resolution on organ donation and transplantation. national
responsibility in meeting the needs of patients, guided by the WHO
principles. Transplantation. 2011;91(Suppl 11):S29–31. https ://doi.
org/10.1097/01.tp.00003 99131 .74618 .a5.
3. Dominguez‑Gil B, Delmonico FL, Shaheen FA, Matesanz R, O’Connor K,
Minina M, et al. The critical pathway for deceased donation: report‑
able uniformity in the approach to deceased donation. Transpl Int.
2011;24:373–8. https ://doi.org/10.1111/j.1432‑2277.2011.01243 .x.
4. DuBose J, Salim A. Aggressive organ donor management protocol. J
Intensive Care Med. 2008;23:367–75. https ://doi.org/10.1177/08850
66608 32420 8.
5. Powner D. Aggressive donor care–to what end? J Intensive Care Med.
2008;23:409–11. https ://doi.org/10.1177/08850 66608 32419 8.
6. Westphal GA, Caldeira Filho M, Vieira KD, Zaclikevis VR, Bartz MC,
Wanzuita R, et al. Guidelines for potential multiple organ donors (adult):
part I. Overview and hemodynamic support. Rev Bras Ter Intensiva.
2011;23:255–68.
7. Westphal GA, Caldeira Filho M, Vieira KD, Zaclikevis VR, Bartz MC, Wan‑
zuita R, et al. Guidelines for potential multiple organ donors (adult): part
II. Mechanical ventilation, endocrine metabolic management, hemato‑
logical and infectious aspects. Rev Bras Ter Intensiva. 2011;23:269–82.
8. Westphal GA, Caldeira Filho M, Vieira KD, Zaclikevis VR, Bartz MC,
Wanzuita R, et al. Guidelines for potential multiple organ donors
(adult). Part III: organ‑specific recommendations. Rev Bras Ter Intensiva.
2011;23:410–25.
9. Schunemann HJ, Moja L. Reviews: rapid! Rapid! Rapid!… and system‑
atic. Syst Rev. 2015;4:4. https ://doi.org/10.1186/2046‑4053‑4‑4.
10. Haby MM, Chapman E, Clark R, Barreto J, Reveiz L, Lavis JN. Designing
a rapid response program to support evidence‑informed decision‑
making in the Americas region: using the best available evidence and
case studies. Implement Sci. 2016;11:117. https ://doi.org/10.1186/s1301
2‑016‑0472‑9.
11. Kotloff RM, Blosser S, Fulda GJ, Malinoski D, Ahya VN, Angel L, et al.
Management of the potential organ donor in the ICU: Society of Critical
Care Medicine/American College of Chest Physicians/Association of
Organ Procurement Organizations Consensus Statement. Crit Care
Med. 2015;43:1291–325. https ://doi.org/10.1097/CCM.00000 00000
00095 8.
12. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck‑Ytter Y, Alonso‑Coello P,
et al. GRADE: an emerging consensus on rating quality of evidence
and strength of recommendations. BMJ. 2008;336:924–6. https ://doi.
org/10.1136/bmj.39489 .47034 7.AD.
13. Mascia L, Zavala E, Bosma K, Pasero D, Decaroli D, Andrews P, et al. High
tidal volume is associated with the development of acute lung injury
after severe brain injury: an international observational study. Crit Care
Med. 2007;35:1815–20. https ://doi.org/10.1097/01.CCM.00002 75269
.77467 .DF.
14. Mascia L, Pasero D, Slutsky AS, Arguis MJ, Berardino M, Grasso S, et al.
Effect of a lung protective strategy for organ donors on eligibility and
availability of lungs for transplantation: a randomized controlled trial.
JAMA. 2010;304:2620–7. https ://doi.org/10.1001/jama.2010.1796.
15. Lebovitz DJ, Reis K, Yun J, Herman L, McCurry KR. An aggressive lung
recruitment protocol increases the percentage of lung donors with
no increased adverse effect in lung recipients: 3173. Transplantation.
2010;90:356.
Page 12 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
16. Noiseux N, Nguyen BK, Marsolais P, Dupont J, Simard L, Houde I, et al.
Pulmonary recruitment protocol for organ donors: a new strategy to
improve the rate of lung utilization. Transplant Proc. 2009;41:3284–9.
https ://doi.org/10.1016/j.trans proce ed.2009.08.041.
17. Gabbay E, Williams TJ, Griffiths AP, Macfarlane LM, Kotsimbos TC, Esmore
DS, et al. Maximizing the utilization of donor organs offered for lung
transplantation. Am J Respir Crit Care Med. 1999;160:265–71. https ://
doi.org/10.1164/ajrcc m.160.1.98110 17.
18. Gattinoni L, Carlesso E, Brazzi L, Caironi P. Positive end‑expiratory
pressure. Curr Opin Crit Care. 2010;16:39–44. https ://doi.org/10.1097/
MCC.0b013 e3283 35472 3.
19. Minambres E, Coll E, Duerto J, Suberviola B, Mons R, Cifrian JM, et al.
Effect of an intensive lung donor‑management protocol on lung trans‑
plantation outcomes. J Heart Lung Transplant. 2014;33:178–84. https ://
doi.org/10.1016/j.healu n.2013.10.034.
20. Angel LF, Levine DJ, Restrepo MI, Johnson S, Sako E, Carpenter A, et al.
Impact of a lung transplantation donor‑management protocol on
lung donation and recipient outcomes. Am J Respir Crit Care Med.
2006;174:710–6. https ://doi.org/10.1164/rccm.20060 3‑432OC .
21. Writing Group for the Alveolar Recruitment for Acute Respiratory
Distress Syndrome Trial I, Cavalcanti AB, Suzumura EA, Laranjeira LN,
Paisani DM, Damiani LP, et al. Effect of lung recruitment and Titrated
Positive End‑Expiratory Pressure (PEEP) vs Low PEEP on mortality in
patients with acute respiratory distress syndrome: a randomized clinical
trial. JAMA. 2017;318:1335–45. https ://doi.org/10.1001/jama.2017.14171
.
22. Gruenberger T, Steininger R, Sautner T, Mittlbock M, Muhlbacher F. Influ‑
ence of donor criteria on postoperative graft function after orthotopic
liver transplantation. Transpl Int. 1994;7(Suppl 1):S672–4. https ://doi.
org/10.1111/j.1432‑2277.1994.tb014 70.x.
23. delaTorre AN, Kuo PC, Plotkin JS, Ridge LA, Howell CD, Bartlett ST, et al.
Influence of donor base deficit status on recipient outcomes in liver
transplantation. Transplant Proc. 1997;29:474. https ://doi.org/10.1016/
s0041 ‑1345(96)00627 ‑6.
24. Westphal GA, Coll E, deSouza RL, Wagner S, Montemezzo A, Cani
de Souza FC, et al. Positive impact of a clinical goal‑directed proto‑
col on reducing cardiac arrests during potential brain‑dead donor
maintenance. Crit Care. 2016;20:323. https ://doi.org/10.1186/s1305
4‑016‑1484‑1.
25. Murugan R, Venkataraman R, Wahed AS, Elder M, Carter M, Madden NJ,
et al. Preload responsiveness is associated with increased interleu‑
kin‑6 and lower organ yield from brain‑dead donors. Crit Care Med.
2009;37:2387–93. https ://doi.org/10.1097/CCM.0b013 e3181 a960d 6.
26. Al‑Khafaji A, Elder M, Lebovitz DJ, Murugan R, Souter M, Stuart S, et al.
Protocolized fluid therapy in brain‑dead donors: the multicenter rand‑
omized MOnIToR trial. Intensive Care Med. 2015;41:418–26. https ://doi.
org/10.1007/s0013 4‑014‑3621‑0.
27. Abdelnour T, Rieke S. Relationship of hormonal resuscitation therapy
and central venous pressure on increasing organs for transplant. J
Heart Lung Transplant. 2009;28:480–5. https ://doi.org/10.1016/j.healu
n.2009.01.018.
28. Minambres E, Perez‑Villares JM, Chico‑Fernandez M, Zabalegui A,
Duenas‑Jurado JM, Misis M, et al. Lung donor treatment protocol
in brain dead‑donors: a multicenter study. J Heart Lung Transplant.
2015;34:773–80. https ://doi.org/10.1016/j.healu n.2014.09.024.
29. Minambres E, Perez‑Villares JM, Terceros‑Almanza L, Duenas‑Jurado JM,
Zabalegui A, Misis M, et al. An intensive lung donor treatment protocol
does not have negative influence on other grafts: a multicentre study.
Eur J Cardiothorac Surg. 2016;49:1719–24. https ://doi.org/10.1093/ejcts
/ezv45 4.
30. Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, et al.
Consensus on circulatory shock and hemodynamic monitoring. Task
force of the European Society of Intensive Care Medicine. Intensive Care
Med. 2014;40:1795–815. https ://doi.org/10.1007/s0013 4‑014‑3525‑z.
31. Schnuelle P, Lorenz D, Mueller A, Trede M, Van Der Woude FJ. Donor
catecholamine use reduces acute allograft rejection and improves graft
survival after cadaveric renal transplantation. Kidney Int. 1999;56:738–
46. https ://doi.org/10.1046/j.1523‑1755.1999.00567 .x.
32. Schnuelle P, Berger S, de Boer J, Persijn G, van der Woude FJ. Effects of
catecholamine application to brain‑dead donors on graft survival in
solid organ transplantation. Transplantation. 2001;72:455–63. https ://
doi.org/10.1097/00007 890‑20010 8150‑00017 .
33. von Ziegler F, Helbig S, Kreissl N, Meiser B, Becker A, Kaczmarek I.
Norepinephrine versus dopamine pretreatment of potential heart
donors‑impact on long‑term outcome. Ann Transplant. 2013;18:320–6.
https ://doi.org/10.12659 /AOT.88396 0.
34. Dictus C, Vienenkoetter B, Esmaeilzadeh M, Unterberg A, Ahmadi
R. Critical care management of potential organ donors: our current
standard. Clin Transplant. 2009;23(Suppl 21):2–9. https ://doi.org/10.1
111/j.1399‑0012.2009.01102 .x.
35. Wood KE, Becker BN, McCartney JG, D’Alessandro AM, Coursin DB.
Care of the potential organ donor. N Engl J Med. 2004;351(26):2730–
9. https ://doi.org/10.1056/NEJMr a0131 03.
36. Marik PE, Baram M, Vahid B. Does central venous pressure predict
fluid responsiveness? A systematic review of the literature and the
tale of seven mares. Chest. 2008;134:172–8. https ://doi.org/10.1378/
chest .07‑2331.
37. Eskesen TG, Wetterslev M, Perner A. Systematic review including
re‑analyses of 1148 individual data sets of central venous pressure as
a predictor of fluid responsiveness. Intensive Care Med. 2016;42:324–
32. https ://doi.org/10.1007/s0013 4‑015‑4168‑4.
38. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial
waveform derived variables and fluid responsiveness in mechani‑
cally ventilated patients: a systematic review of the literature. Crit
Care Med. 2009;37:2642–7. https ://doi.org/10.1097/CCM.0b013 e3181
a590d a.
39. Rui Q, Jiang Y, Chen M, Zhang N, Yang H, Zhou Y. Dopamine versus
norepinephrine in the treatment of cardiogenic shock: a PRISMA‑
compliant meta‑analysis. Medicine. 2017;96:e8402. https ://doi.
org/10.1097/MD.00000 00000 00840 2.
40. Benck U, Hoeger S, Brinkkoetter PT, Gottmann U, Doenmez D,
Boesebeck D, et al. Effects of donor pre‑treatment with dopamine
on survival after heart transplantation: a cohort study of heart
transplant recipients nested in a randomized controlled multicenter
trial. J Am Coll Cardiol. 2011;58:1768–77. https ://doi.org/10.1016/j.
jacc.2011.05.060.
41. Schnuelle P, Gottmann U, Hoeger S, Boesebeck D, Lauchart W, Weiss C,
et al. Effects of donor pretreatment with dopamine on graft function
after kidney transplantation: a randomized controlled trial. JAMA.
2009;302:1067–75. https ://doi.org/10.1001/jama.2009.1310.
42. Schnuelle P, Schmitt WH, Weiss C, Habicht A, Renders L, Zeier M,
et al. Effects of dopamine donor pretreatment on graft survival after
kidney transplantation: a randomized trial. Clin J Am Soc Nephrol.
2017;12:493–501. https ://doi.org/10.2215/CJN.07600 716.
43. Benck U, Jung M, Kruger B, Grimm A, Weiss C, Yard BA, et al. Donor
Dopamine Does Not Affect Liver Graft Survival: evidence of Safety From
a Randomized Controlled Trial. Liver Transpl. 2018;24:1336–45. https ://
doi.org/10.1002/lt.25301 .
44. Iwai A, Sakano T, Uenishi M, Sugimoto H, Yoshioka T, Sugimoto T. Effects
of vasopressin and catecholamines on the maintenance of circulatory
stability in brain‑dead patients. Transplantation. 1989;48:613–7.
45. Kinoshita Y, Yahata K, Yoshioka T, Onishi S, Sugimoto T. Long‑term renal
preservation after brain death maintained with vasopressin and epi‑
nephrine. Transpl Int. 1990;3:15–8. https ://doi.org/10.1007/bf003 33196 .
46. Pennefather SH, Bullock RE, Mantle D, Dark JH. Use of low dose arginine
vasopressin to support brain‑dead organ donors. Transplantation.
1995;59:58–62. https ://doi.org/10.1097/00007 890‑19950 1150‑00011 .
47. Plurad DS, Bricker S, Neville A, Bongard F, Putnam B. Arginine vasopres‑
sin significantly increases the rate of successful organ procurement in
potential donors. Am J Surg. 2012;204:856–60. https ://doi.org/10.1016/j.
amjsu rg.2012.05.011.
48. Chen JM, Cullinane S, Spanier TB, Artrip JH, John R, Edwards NM, et al.
Vasopressin deficiency and pressor hypersensitivity in hemodynami‑
cally unstable organ donors. Circulation. 1999;100:244–6. https ://doi.
org/10.1161/01.cir.100.suppl _2.ii‑244.
49. K atz K, Lawler J, Wax J, O’Connor R, Nadkarni V. Vasopressin pressor
effects in critically ill children during evaluation for brain death and
organ recovery. Resuscitation. 2000;47:33–40. https ://doi.org/10.1016/
s0300 ‑9572(00)00196 ‑9.
50. Benck U, Gottmann U, Hoeger S, Lammert A, Rose D, Boesebeck D, et al.
Donor desmopressin is associated with superior graft survival after
Page 13 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
kidney transplantation. Transplantation. 2011;92:1252–8. https ://doi.
org/10.1097/TP.0b013 e3182 36cd4 c.
51. Shemie SD, Ross H, Pagliarello J, Baker AJ, Greig PD, Brand T, et al.
Organ donor management in Canada: recommendations of the forum
on Medical Management to Optimize Donor Organ Potential. CMAJ.
2006;174:S13–32. https ://doi.org/10.1503/cmaj.04513 1.
52. Gramm HJ, Meinhold H, Bickel U, Zimmermann J, von Hammerstein B,
Keller F, et al. Acute endocrine failure after brain death? Transplantation.
1992;54:851–7. https ://doi.org/10.1097/00007 890‑19921 1000‑00016 .
53. Fiser DH, Jimenez JF, Wrape V, Woody R. Diabetes insipidus in
children with brain death. Crit Care Med. 1987;15:551–3. https ://doi.
org/10.1097/00003 246‑19870 6000‑00002 .
54. Follette DM, Rudich SM, Babcock WD. Improved oxygenation and
increased lung donor recovery with high‑dose steroid administration
after brain death. J Heart Lung Transplant. 1998;17:423–9. https ://doi.
org/10.1007/s8010 90000 086.
55. Dhar R, Cotton C, Coleman J, Brockmeier D, Kappel D, Marklin G,
et al. Comparison of high‑ and low‑dose corticosteroid regimens for
organ donor management. J Crit Care. 2013;28(111):e1–7. https ://doi.
org/10.1007/s8010 90000 086.
56. Jafari R, Aflatoonian R, Falak R, Pourmand G, Dehghani S, Mortazavi M,
et al. Down‑regulation of inflammatory signaling pathways despite
up‑regulation of Toll‑like receptors; the effects of corticosteroid therapy
in brain‑dead kidney donors, a double‑blind, randomized, controlled
trial. Mol Immunol. 2018;94:36–44. https ://doi.org/10.1016/j.molim
m.2017.12.012.
57. Dupuis S, Amiel JA, Desgroseilliers M, Williamson DR, Thiboutot Z, Serri
K, et al. Corticosteroids in the management of brain‑dead potential
organ donors: a systematic review. Br J Anaesth. 2014;113:346–59. https
://doi.org/10.1093/bja/aeu15 4.
58. Pinsard M, Ragot S, Mertes PM, Bleichner JP, Zitouni S, Cook F, et al.
Interest of low‑dose hydrocortisone therapy during brain‑dead organ
donor resuscitation: the CORTICOME study. Crit Care. 2014;18:R158.
https ://doi.org/10.1186/cc139 97.
59. Venkateswaran RV, Steeds RP, Quinn DW, Nightingale P, Wilson IC,
Mascaro JG, et al. The haemodynamic effects of adjunctive hormone
therapy in potential heart donors: a prospective randomized double‑
blind factorially designed controlled trial. Eur Heart J. 2009;30:1771–80.
https ://doi.org/10.1093/eurhe artj/ehp08 6.
60. Perez‑Blanco A, Caturla‑Such J, Canovas‑Robles J, Sanchez‑Paya J.
Efficiency of triiodothyronine treatment on organ donor hemodynamic
management and adenine nucleotide concentration. Intensive Care
Med. 2005;31:943–8. https ://doi.org/10.1007/s0013 4‑005‑2662‑9.
61. Jeevanandam V. Triiodothyronine: spectrum of use in heart transplanta‑
tion. Thyroid. 1997;7:139–45. https ://doi.org/10.1089/thy.1997.7.139.
62. Goarin JP, Cohen S, Riou B, Jacquens Y, Guesde R, Le Bret F, et al. The
effects of triiodothyronine on hemodynamic status and cardiac func‑
tion in potential heart donors. Anesth Analg. 1996;83:41–7. https ://doi.
org/10.1097/00000 539‑19960 7000‑00008 .
63. Randell TT, Hockerstedt KA. Triiodothyronine treatment in brain‑dead
multiorgan donors–a controlled study. Transplantation. 1992;54:736–8.
https ://doi.org/10.1097/00007 890‑19921 0000‑00034 .
64. Garcia‑Fages LC, Antolin M, Cabrer C, Talbot R, Alcaraz A, Lozano F, et al.
Effects of substitutive triiodothyronine therapy on intracellular nucleo‑
tide levels in donor organs. Transplant Proc. 1991;23:2495–6.
65. Mariot J, Jacob F, Voltz C, Perrier JF, Strub P. Value of hormonal treatment
with triiodothyronine and cortisone in brain dead patients. Ann Fr
Anesth Reanim. 1991;10:321–8. https ://doi.org/10.1007/s8010 90000
086.
66. Macdonald PS, Aneman A, Bhonagiri D, Jones D, O’Callaghan G, Sil‑
vester W, et al. A systematic review and meta‑analysis of clinical trials of
thyroid hormone administration to brain dead potential organ donors.
Crit Care Med. 2012;40:1635–44. https ://doi.org/10.1097/CCM.0b013
e3182 416ee 7.
67. Rech TH, Moraes RB, Crispim D, Czepielewski MA, Leitao CB. Manage‑
ment of the brain‑dead organ donor: a systematic review and meta‑
analysis. Transplantation. 2013;95:966–74. https ://doi.org/10.1097/
TP.0b013 e3182 83298 e.
68. Dhar R, Stahlschmidt E, Marklin G. A randomized trial of intravenous
thyroxine for brain‑dead organ donors with impaired cardiac function.
Prog Transplant. 2020;30:48–55. https ://doi.org/10.1177/15269 24819
89329 5.
69. Dhar R, Stahlschmidt E, Yan Y, Marklin G. A randomized trial comparing
triiodothyronine (T3) with thyroxine (T4) for hemodynamically unstable
brain‑dead organ donors. Clin Transplant. 2019;33:e13486. https ://doi.
org/10.1111/ctr.13486 .
70. Hesse UJ, Sutherland DE. Influence of serum amylase and plasma glu‑
cose levels in pancreas cadaver donors on graft function in recipients.
Diabetes. 1989;38(Suppl 1):1–3. https ://doi.org/10.2337/diab.38.1.s1.
71. Gores PF, Gillingham KJ, Dunn DL, Moudry‑Munns KC, Najarian JS,
Sutherland DE. Donor hyperglycemia as a minor risk factor and
immunologic variables as major risk factors for pancreas allograft loss
in a multivariate analysis of a single institution’s experience. Ann Surg.
1992;215:217–30. https ://doi.org/10.1097/00000 658‑19920 3000‑00005 .
72. Masson F, Thicoipe M, Gin H, de Mascarel A, Angibeau RM, Favarel‑
Garrigues JF, et al. The endocrine pancreas in brain‑dead donors. A
prospective study in 25 patients. Transplantation. 1993;56:363–7. https
://doi.org/10.1097/00007 890‑19930 8000‑00022 .
73. Odorico JS, Heisey DM, Voss BJ, Steiner DS, Knechtle SJ, D’Alessandro
AM, et al. Donor factors affecting outcome after pancreas transplanta‑
tion. Transplant Proc. 1998;30:276–7. https ://doi.org/10.1016/s0041
‑1345(97)01263 ‑3.
74. Shaffer D, Madras PN, Sahyoun AI, Simpson MA, Monaco AP. Cadaver
donor hyperglycemia does not impair long‑term pancreas allograft
survival or function. Transplant Proc. 1994;26:439–40.
75. Blasi‑Ibanez A, Hirose R, Feiner J, Freise C, Stock PG, Roberts JP, et al.
Predictors associated with terminal renal function in deceased organ
donors in the intensive care unit. Anesthesiology. 2009;110:333–41.
https ://doi.org/10.1097/ALN.0b013 e3181 94ca8 a.
76. Perez‑Protto SE, Reynolds LF, Dalton JE, Taketomi T, Irefin SA, Parker BM,
et al. Deceased donor hyperglycemia and liver graft dysfunction. Prog
Transplant. 2014;24:106–12. https ://doi.org/10.7182/pit20 14737 .
77. Sally MB, Ewing T, Crutchfield M, Patel MS, Raza S, DeLaCruz S, et al.
Determining optimal threshold for glucose control in organ donors
after neurologic determination of death: a United Network for Organ
Sharing Region 5 Donor Management Goals Workgroup prospec‑
tive analysis. J Trauma Acute Care Surg. 2014;76:62–8. https ://doi.
org/10.1097/ta.0b013 e3182 ab0d9 b.
78. Patel MS, Zatarain J, De La Cruz S, Sally MB, Ewing T, Crutchfield M, et al.
The impact of meeting donor management goals on the number of
organs transplanted per expanded criteria donor: a prospective study
from the UNOS Region 5 Donor Management Goals Workgroup. JAMA
Surg. 2014;149:969–75. https ://doi.org/10.1001/jamas urg.2014.967.
79. Khosravi MB, Firoozifar M, Ghaffaripour S, Sahmeddini MA, Eghbal MH.
Early outcomes of liver transplants in patients receiving organs from
hypernatremic donors. Exp Clin Transplant. 2013;11:537–40. https ://doi.
org/10.6002/ect.2012.0274.
80. K aseje N, McLin V, Toso C, Poncet A, Wildhaber BE. Donor hypernatremia
before procurement and early outcomes following pediatric liver
transplantation. Liver Transpl. 2015;21:1076–81. https ://doi.org/10.1002/
lt.24145 .
81. Mangus RS, Fridell JA, Vianna RM, Milgrom ML, Chestovich P, Vanden‑
boom C, et al. Severe hypernatremia in deceased liver donors does
not impact early transplant outcome. Transplantation. 2010;90:438–43.
https ://doi.org/10.1097/TP.0b013 e3181 e764c 0.
82. K aczmarek I, Tenderich G, Groetzner J, Deutsch MA, Schulz U, Beiras‑
Fernandez A, et al. The controversy of donor serum sodium levels in
heart transplantation ‑ a multicenter experience. Thorac Cardiovasc
Surg. 2006;54:313–6. https ://doi.org/10.1055/s‑2006‑92388 9.
83. Totsuka E, Dodson F, Urakami A, Moras N, Ishii T, Lee MC, et al. Influence
of high donor serum sodium levels on early postoperative graft func‑
tion in human liver transplantation: effect of correction of donor hyper‑
natremia. Liver Transpl Surg. 1999;5:421–8. https ://doi.org/10.1002/
lt.50005 0510.
84. Dawwas MF, Lewsey JD, Neuberger JM, Gimson AE. The impact of
serum sodium concentration on mortality after liver transplantation: a
cohort multicenter study. Liver Transpl. 2007;13:1115–24. https ://doi.
org/10.1002/lt.21154 .
85. Cywinski JB, Mascha E, Miller C, Eghtesad B, Nakagawa S, Vincent JP,
et al. Association between donor‑recipient serum sodium differences
Page 14 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
and orthotopic liver transplant graft function. Liver Transpl. 2008;14:59–
65. https ://doi.org/10.1002/lt.21305 .
86. Mousavi SA, Shahabi S, Mostafapour E, Purfakharan M, Fereshteh‑
nejad SM, Amini J, et al. Comparison of the serum electrolyte levels
among patients died and survived in the intensive care unit. Tanaffos.
2012;11:36–42.
87. Chen M, Sun R, Hu B. The influence of serum magnesium level
on the prognosis of critically ill patients. Zhonghua Wei Zhong
Bing Ji Jiu Yi Xue. 2015;27:213–7. https ://doi.org/10.3760/cma.j.i
ssn.2095‑4352.2015.03.011.
88. Kumar S, Honmode A, Jain S, Bhagat V. Does magnesium matter in
patients of Medical Intensive Care Unit: a study in rural Central India.
Indian J Crit Care Med. 2015;19:379–83. https ://doi.org/10.4103/0972‑
5229.16027 2.
89. Velissaris D, Karamouzos V, Pierrakos C, Aretha D, Karanikolas M.
Hypomagnesemia in critically ill sepsis patients. J Clin Med Res.
2015;7:911–8. https ://doi.org/10.14740 /jocmr 2351w .
90. Thel MC, Armstrong AL, McNulty SE, Califf RM, O’Connor CM. Ran‑
domised trial of magnesium in in‑hospital cardiac arrest. Duke Internal
Medicine Housestaff. Lancet. 1997;350:1272–6. https ://doi.org/10.1016/
s0140 ‑6736(97)05048 ‑4.
91. Smith LF, Heagerty AM, Bing RF, Barnett DB. Intravenous infusion of
magnesium sulphate after acute myocardial infarction: effects on
arrhythmias and mortality. Int J Cardiol. 1986;12:175–83. https ://doi.
org/10.1016/0167‑5273(86)90239 ‑1.
92. Alves SC, Tomasi CD, Constantino L, Giombelli V, Candal R, Bristot Mde L,
et al. Hypomagnesemia as a risk factor for the non‑recovery of the renal
function in critically ill patients with acute kidney injury. Nephrol Dial
Transplant. 2013;28:910–6. https ://doi.org/10.1093/ndt/gfs26 8.
93. Powner DJ. Factors during donor care that may affect liver transplanta‑
tion outcome. Prog Transplant. 2004;14:241–7. https ://doi.org/10.7182/
prtr.14.3.d36p8 205k2 02527 4.
94. Adam R, Reynes M, Bao YM, Astarcioglu I, Azoulay D, Chiche L, et al.
Impact of glycogen content of the donor liver in clinical liver transplan‑
tation. Transplant Proc. 1993;25:1536–7.
95. Powner DJ, Bernstein IM. Extended somatic support for pregnant
women after brain death. Crit Care Med. 2003;31:1241–9. https ://doi.
org/10.1097/01.CCM.00000 59643 .45027 .96.
96. Dominguez‑Roldan JM, Murillo‑Cabezas F, Santamaria‑Mifsut JL,
Munoz‑Sanchez A, Villen‑Nieto J, Barrera‑Chacon JM. Changes in resting
energy expenditure after development of brain death. Transplant Proc.
1995;27:2397–8.
97. Little DM, Farrell JG, Cunningham PM, Hickey DP. Donor sepsis is not
a contraindication to cadaveric organ donation. QJM. 1997;90:641–2.
https ://doi.org/10.1093/qjmed /90.10.641.
98. Zibari GB, Lipka J, Zizzi H, Abreo KD, Jacobbi L, McDonald JC. The use
of contaminated donor organs in transplantation. Clin Transplant.
2000;14:397–400. https ://doi.org/10.1034/j.1399‑0012.2000.14040 702.x.
99. Lumbreras C, Sanz F, Gonzalez A, Perez G, Ramos MJ, Aguado JM, et al.
Clinical significance of donor‑unrecognized bacteremia in the outcome
of solid‑organ transplant recipients. Clin Infect Dis. 2001;33:722–6. https
://doi.org/10.1086/32259 9.
100. Caballero F, Lopez‑Navidad A, Perea M, Cabrer C, Guirado L, Sola R.
Successful liver and kidney transplantation from cadaveric donors with
left‑sided bacterial endocarditis. Am J Transplant. 2005;5:781–7. https ://
doi.org/10.1111/j.1600‑6143.2005.00773 .x.
101. Len O, Gavalda J, Blanes M, Montejo M, San Juan R, Moreno A,
et al. Donor infection and transmission to the recipient of a solid
allograft. Am J Transplant. 2008;8:2420–5. https ://doi.org/10.111
1/j.1600‑6143.2008.02397 .x.
102. Sozen H, Fidan K, Mahli A, Singin E, Buyan N, Sindel S, et al. Successful
solid organ transplantation from septicemic cadaveric donors: case
report. Transplant Proc. 2008;40:299–301. https ://doi.org/10.1016/j.trans
proce ed.2007.11.044.
103. Lin TL, Kuo SC, Yeh CH, Chan YC, Lin YH, Li WF, et al. Donor‑transmitted
bacterial infection in deceased donor liver transplantation: experience
of Southern Taiwan Medical Center. Transplant Proc. 2018;50:2711–4.
https ://doi.org/10.1016/j.trans proce ed.2018.04.017.
104. Corman Dincer P, Tore Altun G, Birtan D, Arslantas R, Sarici Mert N,
Ozdemir I, et al. Incidence and risk factors for systemic infection
in deceased donors. Transplant Proc. 2019;51:2195–7. https ://doi.
org/10.1016/j.trans proce ed.2019.03.054.
105. Kubak BM, Gregson AL, Pegues DA, Leibowitz MR, Carlson M, Marelli
D, et al. Use of hearts transplanted from donors with severe sepsis and
infectious deaths. J Heart Lung Transplant. 2009;28:260–5. https ://doi.
org/10.1016/j.healu n.2008.11.911.
106. Outerelo C, Gouveia R, Mateus A, Cruz P, Oliveira C, Ramos A. Infected
donors in renal transplantation: expanding the donor pool. Trans‑
plant Proc. 2013;45:1054–6. https ://doi.org/10.1016/j.trans proce
ed.2013.02.014.
107. Freeman RB, Giatras I, Falagas ME, Supran S, O’Connor K, Bradley J,
et al. Outcome of transplantation of organs procured from bac‑
teremic donors. Transplantation. 1999;68:1107–11. https ://doi.
org/10.1097/00007 890‑19991 0270‑00008 .
108. Cerutti E, Stratta C, Romagnoli R, Serra R, Lepore M, Fop F, et al. Bacte‑
rial‑ and fungal‑positive cultures in organ donors: clinical impact in liver
transplantation. Liver Transpl. 2006;12:1253–9. https ://doi.org/10.1002/
lt.20811 .
109. Angelis M, Cooper JT, Freeman RB. Impact of donor infections on out‑
come of orthotopic liver transplantation. Liver Transpl. 2003;9:451–62.
https ://doi.org/10.1053/jlts.2003.50094 .
110. Ruiz I, Gavalda J, Monforte V, Len O, Roman A, Bravo C, et al. Donor‑to‑
host transmission of bacterial and fungal infections in lung trans‑
plantation. Am J Transplant. 2006;6:178–82. https ://doi.org/10.111
1/j.1600‑6143.2005.01145 .x.
111. Niemann CU, Feiner J, Swain S, Bunting S, Friedman M, Crutchfield M,
et al. Therapeutic hypothermia in deceased organ donors and kidney‑
graft function. N Engl J Med. 2015;373:405–14. https ://doi.org/10.1056/
NEJMo a1501 969.
112. Schnuelle P, Mundt HM, Druschler F, Schmitt WH, Yard BA, Kramer BK,
et al. Impact of spontaneous donor hypothermia on graft outcomes
after kidney transplantation. Am J Transplant. 2018;18:704–14. https ://
doi.org/10.1111/ajt.14541 .
113. Schnuelle P, Benck U, Kramer BK, Yard BA, Zuckermann A, Wagner F,
et al. Impact of donor core body temperature on graft survival after
heart transplantation. Transplantation. 2018;102:1891–900. https ://doi.
org/10.1097/TP.00000 00000 00233 7.
114. Huang FY, Huang BT, Wang PJ, Zuo ZL, Heng Y, Xia TL, et al. The efficacy
and safety of prehospital therapeutic hypothermia in patients with
out‑of‑hospital cardiac arrest: a systematic review and meta‑analysis.
Resuscitation. 2015;96:170–9. https ://doi.org/10.1016/j.resus citat
ion.2015.08.005.
115. Axelrod DA, Malinoski D, Patel MS, Broglio K, Lewis R, Groat T, et al. Mod‑
eling the economic benefit of targeted mild hypothermia in deceased
donor kidney transplantation. Clin Transplant. 2019;33:e13626. https ://
doi.org/10.1111/ctr.13626 .
116. de la Cruz JS, Sally MB, Zatarain JR, Crutchfield M, Ramsey K, Nielsen J,
et al. The impact of blood transfusions in deceased organ donors on
the outcomes of 1884 renal grafts from United Network for Organ Shar‑
ing Region 5. J Trauma Acute Care Surg. 2015;79:S164–70. https ://doi.
org/10.1097/TA.00000 00000 00067 0.
117. van Erp AC, van Dullemen LFA, Ploeg RJ, Leuvenink HGD. Systematic
review on the treatment of deceased organ donors. Transplant Rev
(Orlando). 2018;32:194–206. https ://doi.org/10.1016/j.trre.2018.06.001.
118. Rosendale JD, Chabalewski FL, McBride MA, Garrity ER, Rosengard
BR, Delmonico FL, et al. Increased transplanted organs from the use
of a standardized donor management protocol. Am J Transplant.
2002;2:761–8. https ://doi.org/10.1034/j.1600‑6143.2002.20810 .x.
119. Salim A, Velmahos GC, Brown C, Belzberg H, Demetriades D. Aggressive
organ donor management significantly increases the number of organs
available for transplantation. J Trauma. 2005;58:991–4. https ://doi.
org/10.1097/01.ta.00001 68708 .78049 .32.
120. Salim A, Martin M, Brown C, Rhee P, Demetriades D, Belzberg H. The
effect of a protocol of aggressive donor management: implications for
the national organ donor shortage. J Trauma. 2006;61:429–33. https ://
doi.org/10.1097/01.ta.00002 28968 .63652 .c1.
121. Malinoski DJ, Daly MC, Patel MS, Oley‑Graybill C, Foster CE, Salim A.
Achieving donor management goals before deceased donor procure‑
ment is associated with more organs transplanted per donor. J Trauma.
2011;71:990–5. https ://doi.org/10.1097/ta.0b013 e3182 2779e 5.
Page 15 of 15
Westphaletal. Ann. Intensive Care (2020) 10:169
122. Malinoski DJ, Patel MS, Daly MC, Oley‑Graybill C, Salim A, workgroup
URD. The impact of meeting donor management goals on the number
of organs transplanted per donor: results from the United Network for
Organ Sharing Region 5 prospective donor management goals study.
Crit Care Med. 2012;40:2773–80. https ://doi.org/10.1097/ccm.0b013
e3182 5b252 a.
123. Marshall GR, Mangus RS, Powelson JA, Fridell JA, Kubal CA, Tector AJ.
Donor management parameters and organ yield: single center results. J
Surg Res. 2014;191:208–13. https ://doi.org/10.1016/j.jss.2014.02.054.
124. Patel MS, De La Cruz S, Sally MB, Groat T, Malinoski DJ. Active donor
management during the hospital phase of care is associated with more
organs transplanted per donor. J Am Coll Surg. 2017;225:525–31. https
://doi.org/10.1016/j.jamco llsur g.2017.06.014.
125. Malinoski DJ, Patel MS, Ahmed O, Daly MC, Mooney S, Graybill CO, et al.
The impact of meeting donor management goals on the develop‑
ment of delayed graft function in kidney transplant recipients. Am J
Transplant. 2013;13:993–1000. https ://doi.org/10.1111/ajt.12090 .
126. Westphal GA, Zaclikevis VR, Vieira KD, Cordeiro Rde B, Horner MB,
Oliveira TP, et al. A managed protocol for treatment of deceased
potential donors reduces the incidence of cardiac arrest before organ
explant. Rev Bras Ter Intensiva. 2012;24:334–40. https ://doi.org/10.1590/
s0103 ‑507x2 01200 04000 07.
127. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al.
A surgical safety checklist to reduce morbidity and mortality in a global
population. N Engl J Med. 2009;360:491–9. https ://doi.org/10.1056/
NEJMs a0810 119.
128. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove
S, et al. An intervention to decrease catheter‑related bloodstream
infections in the ICU. N Engl J Med. 2006;355:2725–32. https ://doi.
org/10.1056/NEJMo a0611 15.
129. Weiss CH, Moazed F, McEvoy CA, Singer BD, Szleifer I, Amaral LA, et al.
Prompting physicians to address a daily checklist and process of care
and clinical outcomes: a single‑site study. Am J Respir Crit Care Med.
2011;184:680–6. https ://doi.org/10.1164/rccm.20110 1‑0037O C.
130. Writing Group for the C‑ICUI, the Brazilian Research in Intensive Care,
Cavalcanti AB, Bozza FA, Machado FR, Salluh JI, et al. Effect of a quality
improvement intervention with daily round checklists, goal setting,
and clinician prompting on mortality of critically ill patients: a rand‑
omized clinical trial. JAMA. 2016;315:1480–90. https ://doi.org/10.1001/
jama.2016.3463.
131. Ball IM, Hornby L, Rochwerg B, Weiss MJ, Gillrie C, Chasse M, et al. Man‑
agement of the neurologically deceased organ donor: a Canadian clini‑
cal practice guideline. CMAJ. 2020;192:E361–9. https ://doi.org/10.1503/
cmaj.19063 1.
132. Meyfroidt G, Gunst J, Martin‑Loeches I, Smith M, Robba C, Taccone FS,
et al. Management of the brain‑dead donor in the ICU: general and
specific therapy to improve transplantable organ quality. Intensive Care
Med. 2019;45:343–53. https ://doi.org/10.1007/s0013 4‑019‑05551 ‑y.
133. National Academies of Sciences, Engineering, and Medicine. Opportu‑
nities for organ donor intervention research: Saving lives by improving
the quality and quantity of organs for transplantation. Washington: The
National Academies Press; 2017.
134. Helms AK, Torbey MT, Hacein‑Bey L, Chyba C, Varelas PN. Standardized
protocols increase organ and tissue donation rates in the neurocriti‑
cal care unit. Neurology. 2004;63:1955–7. https ://doi.org/10.1212/01.
wnl.00001 44197 .06562 .24.
135. Franklin GA, Santos AP, Smith JW, Galbraith S, Harbrecht BG, Garrison
RN. Optimization of donor management goals yields increased organ
use. Am Surg. 2010;76:587–94.
136. Westphal GA, Robinson CC, Biasi A, Machado FR, Rosa RG, Teixeira C,
et al. 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 inten‑
sive care units, a cluster randomised trial. BMJ Open. 2019;9:e028570.
https ://doi.org/10.1136/bmjop en‑2018‑02857 0.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub‑
lished maps and institutional affiliations.
