Herz-Kreislauf-Stillstand und milde therapeutische Hypothermie

Zusammenfassung

Die milde therapeutische Hypothermie (MTM) nach kardiopulmonaler Reanimation (CPR) wird zunehmend als neuroprotektiver Therapieansatz in der Post-Reanimationsphase anerkannt. Dabei vermag der frühzeitige Einsatz der MTH nach CPR das Ausmaß neuronaler Schäden zu reduzieren, insbesondere bei Kühlbeginn schon vor Wiederherstellung des Spontankreislaufs (Prä-ROSC). Aber auch die später induzierte MTH, bis 4 Stunden nach CPR, führt zur Verbesserung der neurologischen Funktion. Die Indikation zur MTH wird nach aktuellen Leitlinien dabei unabhängig vom initialen Herzrhythmus gestellt. Auch für Patienten mit nicht defibrillierbarem Herzrhythmus weisen klinische Studien auf ein besseres neurologisches Überleben durch MTH hin, obwohl die Überlebensrate per se schlechter als bei initialem Kammerflimmern ist. Die Durchführung der MTH bei CPR ist in vielen Detailfragen noch nicht vollständig geklärt, dennoch ist man sich über einige Eckpunkte einig – wie rascher Kühlbeginn und Erreichen der Zieltemperatur von 34 – 32 °C, Aufrechterhaltung dieser Temperatur für 12 – 24 Stunden und langsame Wiedererwärmung. Die Induktion gelingt mit einfach applizierbaren Systemen, die nach Kreislaufstabilisierung durch endovaskuläre oder transkutane Erhaltungssysteme mit feedbackgesteuerter Temperaturmessung ersetzt werden sollten. Während der Behandlung ist auf „geräteassoziierte“ und „methodenassoziierte“ Nebenwirkungen zu achten, die insgesamt zwar gering sind, im Einzelfall das Outcome jedoch negativ beeinflussen. Frühestens 72 Stunden nach CPR ist eine erste Prognoseabschätzung zur zerebralen Restauration sinnvoll, wobei nach 7 Tagen eine Reevaluierung empfohlen wird.

Abstract

Mild therapeutic hypothermia (MTH) has become widely accepted after cardiopulmonary resuscitation (CPR) to date. MTH should be induced as soon as possible. First reports recommend the induction already during CPR (Pre-ROSC). This very early induction seems of more benefit in terms of neurologic recovery. But, MTH may act in a delayed post-reperfusion window too. Though a number of details are not fully understood the current recommendation for MTH in CPR patients include cooling independent from initial heart rhythm, as soon as possible to 34 – 32 °C for 12 – 24 hours and a slow rewarming. Induction of MTH should be done with simple methods with high efficiency. After stabilisation of the patients, a feedback temperature-controlled endovascular or transcutaneous device for maintenance should be applied. MTH is accompanied by “device-associated” and “method-specific” side effects. Severe side effects are generally rare, but have to be considered to avoid an impairment of the individual outcome. A prognostication of neurologic outcome after MTH in CPR patients should carefully be done at the earliest three days after resuscitation. The interpretation has to consider several prognostic parameters. A reevaluation at day seven is indispensable.

Schlüsselwörter

milde therapeutische Hypothermie - kardiopulmonale Reanimation - Prä-ROSC-Kühlung - Post-ROSC-Kühlung

Keywords

mild therapeutic hypothermia - cardiopulmonary resuscitation - pre-ROSC-cooling - post-ROSC-cooling

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