Michalski Dominik, Weidhase Lorenz, Pfeifer Felix, Englbrecht Jan Sönke, Hahnenkamp Klaus, Ziganshyna Svitlana
Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland.
Stabsstelle Transplantationsbeauftragte, Universitätsklinikum Leipzig, Philipp-Rosenthal-Str. 27b, 04103, Leipzig, Deutschland.
Anaesthesiologie. 2025 Aug 25. doi: 10.1007/s00101-025-01573-y.
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.
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.
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.
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.
德国医学协会2025年修订的供体识别指南重申了器官保护性重症监护或在即将发生或已确定的不可逆脑功能丧失（脑死亡）情况下应用强化医疗措施以维持器官功能的重要性。这些措施旨在为已声明愿意捐赠或捐赠状态仍不确定的患者保留器官捐赠的可能性。目前，德国在这方面尚无基于证据的重症监护管理指南。本综述旨在为重度脑损伤且即将发生或已确诊脑死亡的成年患者的器官保护性重症监护和器官功能维持策略提供实用指导。
本综述基于从数据库（PubMed/Medline）检索到的相关英文和德文出版物以及国际指南和专家行动建议。
从即将发生脑死亡到确诊脑死亡以及随后的阶段，会发生各种病理生理变化，这些变化对器官保护性重症监护和器官功能维持具有影响。这些变化包括血流动力学、肺功能、内分泌系统紊乱以及感染并发症。此外，一些措施侧重于器官获取后的保护。基于队列研究和登记研究以及少数随机试验，诸如静脉注射血管加压素和糖皮质激素以及包括肺复张手法在内的持续肺保护性通气等干预措施，在某些情况下似乎可改善血流动力学和肺功能；然而，总体证据仍然有限，诸如血管加压素或糖皮质激素给药的最佳时机等关键问题仍未解决。其他干预措施，如甲状腺激素替代、低阈值胰岛素给药以及多巴胺的使用，仍存在争议。
从当前文献中可以得出关于在脑死亡背景下使用器官保护性重症监护或器官功能维持策略的建议，主要是在诸如血流动力学不稳定等特定条件下。因此，在临床实践中应采用重症监护的一般标准。迫切需要进一步的研究举措来解决特定的医学干预措施和医疗保健供应方面的问题。这可以通过随机试验以及德国国家移植登记处的进一步发展来实现，这将为产生可靠的临床见解奠定基础。
