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Table 2 Results of the 65 key interventions for which consensus was reached by the overall panel after the third Delphi round

From: Development of key interventions and quality indicators for the management of an adult potential donor after brain death: a RAND modified Delphi approach

  Based on literature (L) or expert panel (E) Median Tertile 7–9 (%) Tertile 7–9 (n) Rating of contribution*
Detection outside the ICU & communication to the ICU
Detection of a patient with a devastating brain injury or lesion with evolution to imminent brain death (for example intracranial hemorrhage, trauma, cerebral ischemia etc.) on a unit outside the ICU (for example emergency services, stroke units, etc.) and early communication of the presence of this patient to the ICU physician (and referral to the ICU). L 8 89% 16 87%
Detection inside the ICU & notification to a transplant center
Detection of a potential donor after brain death inside the ICU.
Detection should be based on defined clinical triggers in patients who have had a devastating brain injury or lesion, while recognizing that clinical situations vary
˗ A Glasgow Coma Scale score of 4 or less that is not explained by sedation and
˗ The absence of one or more cranial nerve reflexes
Unless there is a clear reason why the above clinical triggers are not met and/or a decision has been made to perform brainstem death tests, whichever is the earlier.
L 9 100% 18 94%
Notification of the donor coordinator at the time these criteria are met. L 9 94% 17 91%
Assessment of the prerequisites prior to the clinical evaluation of brain death:
˗ Coma, irreversible, and cause known.
˗ Neuroimaging compatible with coma.
˗ Central nervous system depressant drug effect absent (if indicated, toxicology screen; if barbiturates given, serum level < 10 μg/mL).
˗ No evidence of residual paralytics (electrical stimulation if paralytics used).
˗ Absence of severe acid-base, electrolyte, and endocrine abnormality.
˗ Normothermia or mild hypothermia (core temperature > 36 °C).
˗ Systolic blood pressure > 100 mmHg. Vasopressors may be required.
˗ No spontaneous respiration.
L 8 89% 16 83%
Approaching the family:
˗ Delivering bad news about the hopeless, medical situation.
˗ Support of the family (physician, nurse, social assistant, psychologist, pastoral service…).
L 9 100% 18 93%
Notification of the potential donor after brain death by an ICUphysician to a transplant center:
˗ Briefing: name, date of birth, diagnosis & therapy, short medical and behavioral history, etc.
˗ Check the medical contra-indications for organ and tissue donation on file with the transplant center.
˗ Is there a registration in the National Register, checked by the transplant center?
L 9 89% 16 91%
Determination of brain death. L 9 100% 18 95%
Legal declaration of death: registration of time of death and the way in which it is determined on a dated and signed official report. L 9 89% 16 93%
Notification of legal authorities if the cause of death is unknown or suspicious. L 9 89% 16 90%
Informing the family about the diagnosis of brain death. L 9 100% 18 98%
Informing the family about the outcome of the National Register and the possibility of organ and tissue donation, preferably in a separated conversation after family understand and accept the diagnosis of brain death. L 9 94% 17 94%
Give clear, unambiguous information about the next main steps about the donation process to the relatives. L 9 100% 18 96%
Feedback about the approach of the family and legal authorities (if the cause of death is unknown or suspicious) and discussion about the necessary investigations for donor evaluation and characterization to a transplant center. L 9 89% 16 90%
Donor evaluation and characterization
Interviewing family and/or other relevant sources (e.g. life partner, cohabitant, caretaker, friend or primary care physician) to obtain the medical and behavioral history of the potential donor which might affect the suitability of the organs for transplantation and imply the risk of disease transmission. L 8 89% 16 89%
Reviewing medical charts to obtain the medical and behavioral history of the potential donor which might affect the suitability of the organs for transplantation and imply the risk of disease transmission. L 9 89% 16 93%
Clinical examination of the potential donor. L 9 89% 16 91%
Collect a blood sample and ship it to a transplant center for appropriate blood tests. L 9 100% 18 93%
Discuss with a transplant center, the necessity to examine a blood sample for the determination of ABO, rhesus blood group or additional laboratory tests. L 9 83% 15 90%
Collect a urine sample (if not shipped to a transplant center) for measurement of sediment, protein & glucose. L 9 83% 15 87%
Perform a chest X-ray, mandatory for each potential donor and to allow evaluation of a potential lung and/or heart donor. L 9 89% 16 90%
Discuss with a transplant center, the necessity to perform a bronchoscopy by an experienced physician to allow evaluation of a potential lung donor together with a bilateral bronchoalveolar lavage to collect samples for microbiological tests and to clear mucous plugs or blood clots that may contribute to impaired oxygenation. L 8 78% 14 81%
Perform an arterial blood gas to allow evaluation of a potential lung donor. L 9 83% 15 88%
Discuss with a transplant center, the necessity to perform an arterial blood gas for a potential lung donor after 10 min ventilation with FiO2 100% & 5 cm H2O PEEP. L 9 83% 15 89%
Perform a 12 lead ECG to allow evaluation of a potential heart donor. L 9 89% 16 90%
Discuss with a transplant center, the necessity to perform a cardiac ultrasound by an experienced physician to allow evaluation of a potential heart donor. L 9 89% 16 89%
Discuss with a transplant center, the necessity to perform, if possible, a coronary angiography if cardiac ultrasound is acceptable but other comorbidities are present. E 8 89% 16 86%
Discuss with a transplant center, the necessity to perform an abdominal ultrasound (or CT scan) to allow evaluation of a potential liver, pancreas and/or kidney donor. L 8 94% 17 88%
Collect the minimum data, as requested by the transplant center for the characterization of organs and donor, on a donor information form and send it together with the results of the investigations to a transplant center. L 9 100% 18 93%
Donor management: general care
Provide at least an arterial line and a central venous line, if not present. L 8 83% 15 86%
Continue appropriate antibiotic therapy and other life supporting pharmacotherapy, only if indicated. L 8 94% 17 90%
Use warming mattress, blankets or warmed intravenous fluids if needed, to prophylactically prevent hypothermia. L 8 78% 14 84%
Reduce vasopressors (if possible) while maintaining hemodynamic stability. L 9 100% 18 92%
Donor management: monitoring
Monitor the core body temperature.
Target temperature: between 35 and 37 °C.
L 8 100% 18 91%
ECG monitoring of heart rate.
Target heart rate between 60 and 100 beats per minute.
L 8 78% 14 83%
Repeat a 12-lead ECG for a potential heart donor if there are subsequent changes in monitored complexes. L 8 83% 15 87%
Invasive arterial pressure monitoring.
Target mean arterial pressure: ≥ 60 mmHg.
L 9 94% 17 91%
Ensuring a recent chest X-ray examination for a potential lung and/or heart donor is available. L 9 89% 16 90%
Monitoring of ventilator parameters. L 9 94% 17 91%
Peripheral oxygen saturation monitoring (SaO2).
Target SaO2: >  95%.
L 9 83% 15 91%
Perform a blood gas analysis on a regular basis.
Target pH: 7.3–7.5.
Target arterial oxygen tension (PaO2): 80–100 mmHg.
Target arterial carbon dioxide tension (PaCO2): 35–45 mmHg.
L 8 89% 16 88%
Send a bronchial secretion sample for microscopy and culture if secretions are present. L 8 89% 16 89%
Perform a bronchoscopy for diagnosis or therapy if clinically indicated. L 8 83% 15 88%
Estimate the effective intravascular volume and overall fluid status by chart review and clinical examination. L 8 78% 14 81%
Monitor hourly urine output, particularly looking for any suggestion of the onset of diabetes insipidus (polyuria).
Target urine output: 0.5–3 mL/kg/h.
L 8 89% 16 90%
Measure blood electrolytes on a regular basis.Target serum sodium: ≤ 155 mEq/L. L 8 89% 16 87%
Measure routine full blood counts to examine the need for transfusion of red blood cells if clinically indicated.
Target hemoglobin: >  7 g/dL.
L 8 78% 14 81%
Donor management: cardiovascular management (hypotension)
Use isotonic crystalloids for intravascular volume replacement and use blood products and colloids (albumin) for specific circumstances. L 8 94% 17 90%
Ensuring an appropriate prescription of vasoactive drugs when correction of the volume deficit fails to achieve the threshold hemodynamic goals. L 9 100% 18 92%
Donor management: cardiovascular management (bradycardia)
Treat bradycardia causing hemodynamic instability, with a short acting β-adrenergic agonist (epinephrine/dopamine/dobutamine/isoprenaline) or occasionally transvenous pacing. Don’t use atropine because bradycardia are the consequence of high-level vagal stimulation and exhibit a high degree of resistance to atropine. L 7 83% 15 81%
Donor management: cardiovascular management (tachycardia)
Treat tachycardia by following the established advanced cardiopulmonary life support guidelines. E 8 89% 16 87%
Donor management: respiratory management
Ensuring a lung protective ventilation is installed:
˗ Minimum FiO2 to obtain a PO2 between 80 and 100 mmHg
˗ Tidal volume (Vt): 6–8 mL/kg (ideal body weight)
˗ Plateau pressure: < 30 cm H2O
˗ PEEP (Positive End Expiratory Pressure): 8–10 cm H2O
L 8 89% 16 85%
Maintain 30–45° head of bed elevation to avoid aspiration. L 8 89% 16 89%
Perform recruitment maneuvers and repeat when indicated. L 8 83% 15 85%
Apply a prescription of oral hygiene every 6 h. L 7 89% 16 84%
Donor management: renal and electrolyte management (oliguria < 0.5 mL/kg/h)
Treat hypovolemia, hypotension and cardiac dysfunction and consider diuretic only if needed. L 9 100% 18 93%
Donor management: renal and electrolyte management (polyuria > 3 mL/kg/h)
Review the medical history, urinary and blood sample to exclude secondary polyuria: osmotic (Mannitol, hyperglycemia), induced (diuretic) or adapted (fluid overload). L 8 100% 18 90%
Confirm diabetes insipidus: urine specific gravity below 1.005 g/mL or trend towards hypernatremia/hyperosmolarity. L 8 94% 17 87%
Treat diabetes insipidus with sufficient fluid volume replacement to compensate polyuria and anti-diuretic hormone replacement.
˗ Fluid volume replacement with monitoring of electrolytes and blood glucose levels.
˗ Anti-diuretic hormone replacement with desmopressin as a first line medication.
L 8 100% 18 93%
Donor management: renal and electrolyte management (electrolyte disturbances)
Treat electrolyte disturbances. L 9 100% 18 93%
Donor management: hormone substitution
Ensuring an appropriate prescription of insulin if treating hyperglycemia to achieve a target glucose level of 180 mg/dL or less. L 8 83% 15 87%
Post procurement care
Detection, registration and reporting of serious adverse events to the transplant center. L 9 100% 18 94%
Debriefing by the donor coordinator and/or transplant coordinator about the results of the transplantation (anonymous) to the relatives, health care professionals and primary care physician. L 9 94% 17 93%
Offering, if necessary, support to the relatives, for example by a feedback conversation after a couple of weeks or information about associations for relatives. E 9 94% 17 93%
Debriefing with the involved health care professionals and transplant coordinator. E 9 89% 16 90%
Ensuring the hospitalization invoice of the patient is excluded of any medical, pharmaceutical or hospital costs after the determination of brain death and legal declaration of death. L 9 94% 17 94%
  1. *rating of contribution = ratio of “sum of ratings on the intervention given by participants” to “sum of ratings on the intervention if all respondents rated the interventions as ‘strongly agree’”
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