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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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Westphal GA, Robinson CC, Cavalcanti AB, Gonçalves ARR, Guterres CM, Teixeira C, Stein C, Franke CA, da Silva DB, Pontes DFS, Nunes DSL, Abdala E, Dal-Pizzol F, Bozza FA, Machado FR, de Andrade J, Cruz LN, de Azevedo LCP, Machado MCV, Rosa RG, Manfro RC, Nothen RR, Lobo SM, Rech TH, Lisboa T, Colpani V, Falavigna M. Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System. Ann Intensive Care 2020; 10:169. [PMID: 33315161 PMCID: PMC7736434 DOI: 10.1186/s13613-020-00787-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To contribute to updating the recommendations for brain-dead potential organ donor management. METHOD A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020. RESULTS A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion). CONCLUSION Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.
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Affiliation(s)
- Glauco Adrieno Westphal
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil. .,Hospital Municipal São José (HMSJ), Joinville, SC, Brazil. .,Centro Hospitalar Unimed, Joinville, SC, Brazil.
| | | | | | - Anderson Ricardo Roman Gonçalves
- Universidade da Região de Joinville (UNIVILLE), R. Paulo Malschitzki, 10, Joinville, SC, 89219710, Brazil.,Clínica de Nefrologia de Joinville, R. Plácido Gomes, 370, Joinville, SC, 89202-050, Brazil
| | - Cátia Moreira Guterres
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cassiano Teixeira
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite, 245, Porto Alegre, RS, 90050-170, Brazil
| | - Cinara Stein
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cristiano Augusto Franke
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Daiana Barbosa da Silva
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Daniela Ferreira Salomão Pontes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Diego Silva Leite Nunes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Edson Abdala
- Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr, Arnaldo 455, Sala 3206, São Paulo, SP, 01246903, Brazil
| | - Felipe Dal-Pizzol
- Universidade do Extremo Sul Catarinense (UNESC), Av. Universitária, 1105, Criciúma, SC, 88806000, Brazil.,Intensive Care Unit, Hospital São José, R. Cel. Pedro Benedet, 630, Criciúma, SC, 88801-250, Brazil
| | - Fernando Augusto Bozza
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Av. Brasil, 4365, Rio de Janeiro, RJ, 21040360, Brazil.,Instituto D'Or de Pesquisa e Ensino (IDOR), R. Diniz Cordeiro, 30, Rio de Janeiro, RJ, 22281100, Brazil
| | - Flávia Ribeiro Machado
- Hospital São Paulo (HU), Universidade Federal de São Paulo (UNIFESP), R. Napoleão de Barros 737, São Paulo, SP, 04024002, Brazil
| | - Joel de Andrade
- Organização de Procura de Órgãos e Tecidos de Santa Catarina (OPO/SC), Rua Esteves Júnior, 390, Florianópolis, SC, 88015130, Brazil
| | - Luciane Nascimento Cruz
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | | | | | - Regis Goulart Rosa
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Roberto Ceratti Manfro
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Rosana Reis Nothen
- Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Suzana Margareth Lobo
- Faculdade de Medicina de São José do Rio Preto, Av Faria Lima, 5544, São José do Rio Preto, SP, 15090000, Brazil
| | - Tatiana Helena Rech
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Thiago Lisboa
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Maicon Falavigna
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil.,National Institute for Health Technology Assessment, UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main St W, Hamilton, ON, Canada
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Giordani NE, Robinson CC, Westphal GA, Rosa RG, Sganzerla D, Cavalcanti AB, Machado FR, Azevedo LCP, Bozza FA, Teixeira C, de Andrade J, Franke CA, Guterres CM, Madalena IC, Rohden AI, da Silva SS, Andrighetto LV, Rech GS, Gimenes BDP, Hammes LS, Pontes DFS, Meade MO, Falavigna M. Statistical analysis plan for a cluster-randomised trial assessing the effectiveness of implementation of a bedside evidence-based checklist for clinical management of brain-dead potential organ donors in intensive care units: DONORS (Donation Network to Optimise Organ Recovery Study). Trials 2020; 21:540. [PMID: 32552839 PMCID: PMC7298918 DOI: 10.1186/s13063-020-04457-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 05/25/2020] [Indexed: 11/28/2022] Open
Abstract
Background The quality of clinical care of brain-dead potential organ donors may help reduce donor losses caused by irreversible or unreversed cardiac arrest and increase the number of organs donated. We sought to determine whether an evidence-based, goal-directed checklist for donor management in intensive care units (ICUs) can reduce donor losses to cardiac arrest. Methods/design The DONORS study is a multicentre, cluster-randomised controlled trial with a 1:1 allocation ratio designed to compare an intervention group (goal-directed checklist for brain-dead potential organ donor management) with a control group (standard ICU care). The primary outcome is loss of potential donors due to cardiac arrest. Secondary outcomes are the number of actual organ donors and the number of solid organs recovered per actual donor. Exploratory outcomes include the achievement of relevant clinical goals during the management of brain-dead potential organ donors. The present statistical analysis plan (SAP) describes all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of the trial. Discussion The SAP of the DONORS study aims to describe its analytic procedures, enhancing the transparency of the study. At the moment of SAP subsmission, 63 institutions have been randomised and were enrolling study participants. Thus, the analyses reported herein have been defined before the end of the study recruitment and database locking. Trial registration ClinicalTrials.gov, NCT03179020. Registered on 7 June 2017.
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Affiliation(s)
- Natalia Elis Giordani
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil. .,Postgraduate Programme in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
| | - Caroline Cabral Robinson
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Glauco Adrieno Westphal
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil.,Hospital Municipal São José, Joinville, SC, Brazil.,Centro Hospitalar Unimed, Joinville, SC, Brazil
| | | | - Daniel Sganzerla
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | | | - Flávia Ribeiro Machado
- Department of Anaesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Fernando Augusto Bozza
- Department of Critical Care and Postgraduate Programme in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil.,Evandro Chagas National Institute of Infectious Diseases, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, Brazil
| | - Cassiano Teixeira
- Department of Internal Medicine and Postgraduate Programme in Rehabilitation Science, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Joel de Andrade
- Organ Procurement Organisation of Santa Catarina (OPO/SC), Florianópolis, SC, Brazil
| | - Cristiano Augusto Franke
- Adult Intensive Care Unit, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.,Trauma Intensive Care Unit, Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Cátia Moreira Guterres
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Itiana Cardoso Madalena
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Adriane Isabel Rohden
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Sabrina Souza da Silva
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Luiza Vitelo Andrighetto
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Gabriela Soares Rech
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Bruna Dos Passos Gimenes
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | | | | | - Maureen O Meade
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maicon Falavigna
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil.,Postgraduate Programme in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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