Abstract
BACKGROUND: The 2025 revision of the donor identification guidelines by the German Medical Association reaffirms the importance of organ-protective intensive care or the application of intensive medical measures to maintain organ function in cases of imminent or established irreversible loss of brain function (brain death). These measures aim to preserve the possibility of organ donation in patients who have declared a willingness to donate or in whom the donation status remains uncertain. Currently, no evidence-based guidelines exist in Germany regarding the intensive care management in this context. This review aims to provide practical guidance on organ-protective intensive care and organ function-preserving strategies in adult patients with severe brain injury and imminent or confirmed brain death. MATERIAL AND METHODS: This review is based on relevant English and German language publications retrieved from databases (PubMed/Medline) as well as international guidelines and expert recommendations for action. RESULTS: Across the continuum from imminent to confirmed brain death and the subsequent phase, various pathophysiological changes occur that have implications for organ-protective intensive care and the maintenance of organ function. These include disturbances in hemodynamics, lung function, the endocrine system and infectious complications. Additionally, some measures focus on organ protection after retrieval. Based on cohort and registry studies and few randomized trials, interventions such as intravenous administration of vasopressin and glucocorticoids as well as consistent lung-protective ventilation including recruitment maneuvers, appear to improve hemodynamics and lung function in certain situations; however, the overall evidence remains limited and key aspects, such as the optimal timing for vasopressin or glucocorticoid administration, remain unresolved. Other interventions, such as thyroid hormone substitution, low-threshold insulin administration, and the use of dopamine, continue to be controversially discussed. DISCUSSION: From the current literature recommendations can be derived regarding the use of organ-protective intensive care or organ function-preserving strategies in the context of brain death, mainly under specific conditions such as hemodynamic instability. In the clinical practice, general standards of intensive care should therefore be applied. Further research initiatives are urgently needed to address both specific medical interventions and healthcare supply aspects. This could be achieved through randomized trials and the further development of the German National Transplantation Registry, which would provide a foundation for generating robust clinical insights.