Contemporary evidence to inform management of deceased potential thoracic organ donors after brain death.

Brain death triggers profound physiologic derangements that threaten organ viability and contribute to the persistent shortage of transplantable thoracic organs. This narrative review synthesizes contemporary evidence informing the management of deceased potential thoracic organ donors after brain death, focusing on clinical studies published over the past decade. We identified 14 trials addressing key aspects of donor management, including lung-protective ventilation strategies, prone positioning, targeted temperature management, hormonal supplementation, and cardiovascular support. Notable findings include validation of lung-protective ventilation with higher positive end-expiratory pressure improving lung recovery rates, observational evidence suggesting that prone position is associated with increased lung and heart procurement, and recent randomized trials demonstrating no benefit from routine levothyroxine administration even in hemodynamically unstable donors. Corticosteroid therapy appears to effectively reduce vasopressor requirements, while newer evidence supports the safety of lower-dose regimens with improved glycemic control. Despite these advances, significant knowledge gaps persist regarding optimal hemodynamic monitoring, vasopressor selection, and other fundamental management decisions. The fragmented nature of the donation and transplantation system presents unique challenges for evidence generation and implementation. Ongoing developments, including donor care units, international collaboration, and innovative trial designs, offer opportunities to address these gaps. This review provides intensivists with an evidence-based framework for optimizing donor management while highlighting priority areas for future research to increase the availability and quality of thoracic organs for transplantation.