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Westphal GA, Robinson CC, Giordani NE, Teixeira C, Rohden AI, Dos Passos Gimenes B, Guterres CM, Madalena IC, Andrighetto LV, Souza da Silva S, Barbosa da Silva D, Sganzerla D, Cavalcanti AB, Franke CA, Bozza FA, Machado FR, de Andrade J, Pontes Azevedo LC, Schneider S, Orlando BR, Grion CMC, Bezerra FA, Roman FR, Leite FO, Ferraz Siqueira ÍL, Oliveira JFP, de Oliveira LC, de Melo MDFRB, Leal PBGP, Diniz PC, Moraes RB, Salomão Pontes DF, Araújo Queiroz JE, Hammes LS, Meade MO, Rosa RG, Falavigna M. Evidence-Based Checklist to Delay Cardiac Arrest in Brain-Dead Potential Organ Donors: The DONORS Cluster Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2346901. [PMID: 38095899 PMCID: PMC10722341 DOI: 10.1001/jamanetworkopen.2023.46901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/25/2023] [Indexed: 12/17/2023] Open
Abstract
Importance The effectiveness of goal-directed care to reduce loss of brain-dead potential donors to cardiac arrest is unclear. Objective To evaluate the effectiveness of an evidence-based, goal-directed checklist in the clinical management of brain-dead potential donors in the intensive care unit (ICU). Design, Setting, and Participants The Donation Network to Optimize Organ Recovery Study (DONORS) was an open-label, parallel-group cluster randomized clinical trial in Brazil. Enrollment and follow-up were conducted from June 20, 2017, to November 30, 2019. Hospital ICUs that reported 10 or more brain deaths in the previous 2 years were included. Consecutive brain-dead potential donors in the ICU aged 14 to 90 years with a condition consistent with brain death after the first clinical examination were enrolled. Participants were randomized to either the intervention group or the control group. The intention-to-treat data analysis was conducted from June 15 to August 30, 2020. Interventions Hospital staff in the intervention group were instructed to administer to brain-dead potential donors in the intervention group an evidence-based checklist with 13 clinical goals and 14 corresponding actions to guide care, every 6 hours, from study enrollment to organ retrieval. The control group provided or received usual care. Main Outcomes and Measures The primary outcome was loss of brain-dead potential donors to cardiac arrest at the individual level. A prespecified sensitivity analysis assessed the effect of adherence to the checklist in the intervention group. Results Among the 1771 brain-dead potential donors screened in 63 hospitals, 1535 were included. These patients included 673 males (59.2%) and had a median (IQR) age of 51 (36.3-62.0) years. The main cause of brain injury was stroke (877 [57.1%]), followed by trauma (485 [31.6%]). Of the 63 hospitals, 31 (49.2%) were assigned to the intervention group (743 [48.4%] brain-dead potential donors) and 32 (50.8%) to the control group (792 [51.6%] brain-dead potential donors). Seventy potential donors (9.4%) at intervention hospitals and 117 (14.8%) at control hospitals met the primary outcome (risk ratio [RR], 0.70; 95% CI, 0.46-1.08; P = .11). The primary outcome rate was lower in those with adherence higher than 79.0% than in the control group (5.3% vs 14.8%; RR, 0.41; 95% CI, 0.22-0.78; P = .006). Conclusions and Relevance This cluster randomized clinical trial was inconclusive in determining whether the overall use of an evidence-based, goal-directed checklist reduced brain-dead potential donor loss to cardiac arrest. The findings suggest that use of such a checklist has limited effectiveness without adherence to the actions recommended in this checklist. Trial Registration ClinicalTrials.gov Identifier: NCT03179020.
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Affiliation(s)
- Glauco A Westphal
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Central Estadual de Transplantes de Santa Catarina, Rua Esteves Júnior, Florianópolis, Santa Catarina, Brazil
- Centro Hospitalar Unimed Joinville and Hospital Municipal São José, Joinville, Santa Catarina, Brazil
| | - Caroline Cabral Robinson
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Natalia Elis Giordani
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Programme in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Cassiano Teixeira
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Adriane Isabel Rohden
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Bruna Dos Passos Gimenes
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Cátia Moreira Guterres
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Itiana Cardoso Madalena
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Luiza Vitelo Andrighetto
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Sabrina Souza da Silva
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Daiana Barbosa da Silva
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Daniel Sganzerla
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Cristiano Augusto Franke
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
- Hospital de Pronto de Socorro (HPS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Fernando Augusto Bozza
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Rio de Janeiro, Brazil
- Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Flávia Ribeiro Machado
- Disciplina de Anestesiologia, Dor e Medicina Intensiva, Universidade Federal de São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
| | - Joel de Andrade
- Central Estadual de Transplantes de Santa Catarina, Rua Esteves Júnior, Florianópolis, Santa Catarina, Brazil
| | | | - Silvana Schneider
- Department of Statistics, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Bianca Rodrigues Orlando
- Hospital Universitário São Francisco de Paula, Pelotas, Rio Grande do Sul, Brazil
- Hospital Escola, Universidade Federal de Pelotas (UFPEL), Pelotas, Rio Grande do Sul, Brazil
| | - Cintia Magalhães Carvalho Grion
- Hospital Universitário Regional do Norte do Paraná, Londrina, Paraná, Brazil
- Hospital Evangélico de Londrina, Londrina, Paraná, Brazil
| | | | | | - Francisco Olon Leite
- Hospital Regional Norte, Centro Universitário Inta (UNINTA), Sobral, Ceará, Brazil
| | | | | | | | | | | | - Pedro Carvalho Diniz
- Hospital Universitário, Universidade Federal do Vale do São Francisco (HU/UNIVASF), Petrolina, Pernambuco, Brazil
| | | | - Daniela Ferreira Salomão Pontes
- General Coordination Office, National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, Distrito Federal, Brazil
| | - Josélio Emar Araújo Queiroz
- General Coordination Office, National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, Distrito Federal, Brazil
| | - Luciano Serpa Hammes
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Maureen O Meade
- Department of Medicine, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Regis Goulart Rosa
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Maicon Falavigna
- Responsabilidade Social-Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- National Institute for Health Technology Assessment, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
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Tannous LA, Westphal GA, Ioshii SO, de Lima Alves GN, Pigatto RN, Pinto RL, de Carvalho KAT, Francisco JC, Guarita-Souza LC. Histological, Laboratorial, and Clinical Benefits of an Optimized Maintenance Strategy of a Potential Organ Donor-A Rabbit Experimental Model. Life (Basel) 2023; 13:1439. [PMID: 37511814 PMCID: PMC10381703 DOI: 10.3390/life13071439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Most transplanted organs are obtained from brain-dead donors. Inflammation results in a higher rate of rejection. Objectives: The objective of this animal model of brain death (BD) was to evaluate the effect of the progressive institution of volume expansion, norepinephrine, and combined hormone therapy on clinical, laboratory, and histological aspects. Methods: Twenty rabbits were divided: A (control), B (induction of BD + infusion of crystalloid), C (BD + infusion of crystalloid and noradrenaline (NA)), and D (BD + infusion of crystalloid + vasopressin + levothyroxine + methylprednisolone + NA). The animals were monitored for four hours with consecutives analysis of vital signs and blood samples. The organs were evaluated by a pathologist. Results: In Group D, we observed fewer number and lesser volume of infusions (p = 0.032/0.014) when compared with groups B and C. Mean arterial pressure levels were higher in group D when compared with group B (p = 0.008). Group D had better glycemic control when compared with group C (p = 0.016). Sodium values were elevated in group B in relation to groups C and D (p = 0.021). In Group D, the organ perfusion was better. Conclusion: The optimized strategy of management of BD animals is associated with better hemodynamic, glycemic, and natremia control, besides reducing early signs of ischemia.
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Affiliation(s)
- Luana Alves Tannous
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | - Sergio Ossamu Ioshii
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | - Raul Nishi Pigatto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | - Rafael Luiz Pinto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | | | - Luiz César Guarita-Souza
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
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Kang HS, Wickramaratne N, Liebrecht LK, Mangino MJ. Effects of polyethylene glycol-20k IV solution on donor management in a canine model of donor brain death. Biomed Pharmacother 2022; 152:113293. [PMID: 35714513 DOI: 10.1016/j.biopha.2022.113293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Traditionally, vasopressors and crystalloids have been used to stabilize brain dead donors; however, the use of crystalloid is fraught with complications. This study aimed to investigate the effectiveness of a newly developed impermeant solution, polyethylene glycol-20k IV solution (PEG-20k) for resuscitation and support of brain dead organ donors. METHODS Brain death was induced in adult beagle dogs and a set volume of PEG-20k or crystalloid solution was given thereafter. The animals were then resuscitated over 16 h with vasopressors and crystalloid as necessary to maintain mean arterial pressure of 80-100 mmHg. The kidneys were procured and cold-stored for 24 h, after which they were analyzed using the isolated perfused kidney model. RESULTS The study group required significantly less crystalloid volume and vasopressors while having less urine output and requiring less potassium supplementation than the control group. Though the two groups' mean arterial pressure and lactate levels were comparable, the study group's kidneys showed less preservation injury after short-term reperfusion indexed by decreased lactate dehydrogenase release and higher creatinine clearance than the control group. CONCLUSIONS The use of polyethylene glycol-20k IV solution for resuscitating brain dead donors decreases cell swelling and improves intravascular volume, thereby improving end organ oxygen delivery before procurement and so preventing ischemia-reperfusion injury after transplantation.
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Affiliation(s)
- Hae Sung Kang
- Departments of Surgery Virginia Commonwealth University, School of Medicine, Richmond, VA 23298, USA
| | - Niluka Wickramaratne
- Departments of Surgery Virginia Commonwealth University, School of Medicine, Richmond, VA 23298, USA
| | - Loren K Liebrecht
- Departments of Surgery Virginia Commonwealth University, School of Medicine, Richmond, VA 23298, USA
| | - Martin J Mangino
- Departments of Surgery Virginia Commonwealth University, School of Medicine, Richmond, VA 23298, USA; Emergency Medicine Virginia Commonwealth University, School of Medicine, Richmond, VA 23298, USA; Physiology and Biophysics Virginia Commonwealth University, School of Medicine, Richmond, VA 23298, USA.
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