Management of adult organ donors after brain death in ICU: insights from an Italian survey

Background: Managing donors after brain death (DBD) is a complex task, but intensivists are believed to play a crucial role in optimizing organ perfusion to enhance organ procurement. This survey aims to gather important data on the practical management of DBD in Italy and to identify areas for potential improvement. Methods: This national survey was conducted online and distributed to all members of the Italian Society of Anesthesia, Analgesia, and Intensive Care (SIAARTI). The questionnaire consisted of 30 questions covering aspects such as the respondents' region of work, level of experience, and workplace characteristics. Clinical questions focused on hemodynamic monitoring and management in the ICU, fluid therapy, mechanical ventilation practices, nutritional habits, and management of endocrine disorders. Additionally, the survey examined practices during the brain death determination process and the organizational procedures involved in organ procurement in the operating room. The data collected were analyzed using descriptive statistics to provide a comprehensive overview of the current practices in DBD management in Italy. Results: From May 4 to August 30, 2024, 364 valid responses have been considered. 63% of respondents reported that they have written guidelines or diagnostic and therapeutic care pathways (PDTA) for DBD, while 34.5% indicated that such pathways do not exist. Nearly 49% of the respondents rely exclusively on standard hemodynamic monitoring techniques. By contrast, 42% incorporate cardiac ultrasound along with both basic and advanced invasive hemodynamic monitoring methods. Norepinephrine was chosen as the preferred treatment by 64.5% of participants. 58% of respondents used balanced crystalloids, while both normal saline and human albumin were used by 20% of them. Most participants implemented protective mechanical ventilation strategies (tidal volume ≤ 6 mL/kg and PEEP ≤ 10cmH2O). Nutrition practices varied significantly among respondents. Additionally, 41% reported that they almost always administered hormonal replacement therapy, while 38% used it only in case of hemodynamic instability. In the assessment of brain death, 43% of physicians performed an apnea test using continuous positive airway pressure without disconnecting the ventilation circuit. The most commonly administered medications during surgery included neuromuscular blocking agents (43%), opioids (42%), inhaled anesthetics (25.5%), propofol (11.5%), and none of the above (3.8%). Conclusions: This survey reflects the current practices of SIAARTI members when managing DBD. It highlights several areas for improvement, particularly the need for written guidelines and PDTA to be readily accessible at every procurement site. Additionally, while protective mechanical ventilation is generally well understood, there is considerable variability in hemodynamic management, fluid strategies, and hormone replacement therapy (HRT). This emphasizes the importance of enhancing education and conducting more targeted research in these critical areas. Trial registration: Not applicable.