Zusammenfassung
Hintergrund
Schon in den 1960er-Jahren postulierten Peter Safar et al. den Benefit einer therapeutischen Hypothermie nach erfolgreicher kardiopulmonaler Reanimation (CPR). In die klinische Routine wurde dieses Verfahren jedoch erst zu Beginn des neuen Jahrtausends eingeführt. Es gibt multiple nichtinvasive und invasive Kühlverfahren. Letztere sind grundsätzlich effektiver, aber auch komplikationsreicher und kommen tendenziell eher später zum Einsatz, was das Erreichen der Zieltemperatur verzögern kann. Gegenstand diverser Diskussionen ist derzeit, wann der genaue Zeitpunkt des optimalen Kühlungsbeginns ist.
Studienlage
Studien mit präklinischer Kühlung haben gegenüber der Kühlung in der Klinik keine Vorteile gezeigt. Die genaue Kühltemperatur ist ebenso umstritten. Eine aktuelle Studie zeigte keinen Nachteil einer Kühlung auf nur 36 ℃ gegenüber 33 ℃, was im – allgemein als sinnvoll akzeptierten – Bereich von 32–34 ℃ liegt. Schlussendlich ist gemäß den immer noch gültigen aktuellen Leitlinien eine Kühlung auf 32–34 ℃ derzeit weiterhin möglich, bis ergänzende Studien zu dem Thema Zieltemperatur neue Erkenntnisse liefern. Ein baldiges Statement des European Resuscitation Councils ist angekündigt. Zudem zeigt sich mittlerweile in weitreichenden Registerstudien, dass neben der Hypothermie die Kombination mit einer akuten perkutanen Koronarintervention (PCI) in einem entsprechenden Zentrum das Überleben sichtbar verbessert.
Ausblick
Da mutmaßlich viele Kreislaufstillstände kardial bedingt sind, macht die Einlieferung in ein „Post-CPR-Zentrum“ mit Möglichkeit zur akuten PCI und Kühlung – vergleichbar wie z. B. der Transport von Polytraumapatienten in Traumazentren – Sinn.
Abstract
Background
In the 1960s, Peter Safar et al. postulated the benefit of postcardiac arrest hypothermia after successful cardiopulmonary resuscitation (CPR). However, therapeutic hypothermia postCPR did not become a standard procedure until the first few years of the new millennium. Various noninvasive and invasive cooling methods are available. Generally, more invasive cooling methods are more effective—but also tend to involve more complications. Furthermore, invasive measures need more time and thus may be instituted late in the postCPR process, delaying the cooling efforts in the initial phase. There is ongoing controversy about when best to commence cooling.
Current situation
Recent studies of initial out-of-hospital cooling did not show any benefit for the patients compared to starting cooling in the hospital. The exact target temperature is the subject of multiple ongoing discussions. A recent study showed no disadvantage of cooling to 36 ℃ compared to 33 ℃, which is in the widely accepted standard target temperature range of 32–34 ℃. Nevertheless, cooling to 32–34 ℃ according to the 2010 guidelines is still the accepted standard procedure unless and until new studies generate more evidence. The European Resuscitation Council has given advance notice of a statement on the optimal target temperature in the near future. Finally, large registry studies have demonstrated the benefit of combining postCPR hypothermia with early percutaneous cardiac interventions (PCI) in acute coronary syndromes, which are often a cause of cardiac arrest.
Outlook
Transport of patients after CPR to specialized postcardiac arrest centres with the possibility of acute PCI and cooling, comparable to the transfer of multiple trauma patients to trauma centres, may be beneficial.
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A. Schneider erhielt Vortragshonorare von Zoll Medical. H. Herff, D. Schröder und B.W. Böttiger erhielten Forschungsunterstützung von der Fa. Hirtz, Köln, Medizinische Kühlsysteme. W. Wetsch gibt an, dass kein Interessenkonflikt besteht.
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Herff, H., Schneider, A., Schröder, D. et al. Therapeutische Hypothermie im Jahr 2015. Med Klin Intensivmed Notfmed 111, 47–51 (2016). https://doi.org/10.1007/s00063-015-0009-z
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DOI: https://doi.org/10.1007/s00063-015-0009-z
Schlüsselwörter
- Kardiopulmonale Reanimation
- Körpertemperatur
- Behandlungsergebnis
- Perkutanen Koronarintervention
- Hypoxischer Hirnschaden