Zusammenfassung
Hintergrund
Aufgrund der fast unverändert ungünstigen Prognose von Patienten nach kardiopulmonaler Wiederbelebung stellt sich dem Intensivmediziner häufig die Frage nach Begrenzung einer aktiven Therapie bei prolongiertem Koma auch unter medizinisch-ethischen Aspekten. Die Vorgeschichte des Patienten sowie die Umstände der Reanimation liefern hierzu nur unzuverlässige Entscheidungshilfen.
Entscheidungsgrundlage
Klinische und elektrophysiologische neurologische Untersuchungstechniken, Biomarker und bildgebende Verfahren bilden die Grundlage für die Beurteilung der Prognose und mögliche konsekutive Therapieentscheidungen. Sedierung, Relaxation und v. a. die therapeutische Hypothermie haben großen Einfluss auf die Untersuchungsergebnisse. Diese Einflüsse sind vor Beurteilung auszuschließen. Nach Hypothermie ist eine ausreichend zuverlässige Beurteilung erst nach Wiedererwärmung möglich. Ebenfalls sollten mehrere Verfahren mit gleichgerichtet ungünstigem Ergebnis vor einer Entscheidung zur Therapiebegrenzung vorliegen. Das Fehlen ungünstiger Zeichen erlaubt allerdings nicht den Umkehrschluss einer guten Prognose.
Schlussfolgerung
Die Entscheidung zur Therapiebegrenzung kann nicht auf Basis eines einzigen prognostisch ungünstigen Zeichens gefällt werden, sondern bedarf einer umfassenden klinischen-diagnostischen Beurteilung.
Abstract
Background
The prognosis of patients who have been resuscitated after cardiac arrest is still unfavourable and long-term results have only slightly improved. As a consequence, intensivists are frequently confronted with the question of limiting active therapeutic efforts for patients in prolonged coma. The history of the patient and circumstances of the resuscitation are of limited value with regard to reliable decisions.
Therapeutic decision-making
Clinical and electrophysiological neurologic techniques as well as biomarkers and diagnostic imaging are, therefore, the basis for prognostication and potential consecutive therapeutic decisions. Sedation, relaxation and particularly therapeutic hypothermia have great influence on the test results. These influences have to be excluded before results can be validated. With regard to therapeutic hypothermia a reliable neurologic evaluation as a basis for limiting treatment is only possible after rewarming. Moreover results of multiple tests should be in agreement before a decision to limit treatment can be made. Finally it must be kept in mind that the absence of unfavourable test results is not proof of a good prognosis.
Conclusion
The decision to limit treatment can not be made on the basis of a single adverse prognostic sign, but requires a comprehensive clinical diagnostic assessment.
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Interessenkonflikt. H.-R. Arntz und H.-C. Mochmann geben an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Arntz, HR., Mochmann, HC. Prognostische Einschätzung als Grundlage für die Therapiebegrenzung bewusstloser Patienten nach kardiopulmonaler Reanimation. Med Klin Intensivmed Notfmed 110, 537–544 (2015). https://doi.org/10.1007/s00063-014-0435-3
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DOI: https://doi.org/10.1007/s00063-014-0435-3