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Neuromonitoring und Neuroprotektion in der Kardioanästhesie

Bundesweite Umfrage des Arbeitskreises Kardioanästhesie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e.V.

Neuromonitoring and neuroprotection in cardiac anaesthesia

Nationwide survey conducted by the Cardiac Anaesthesia Working Group of the German Society of Anaesthesiology and Intensive Care Medicine

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Zusammenfassung

Fragestellung

Primäres Ziel dieser in deutschen kardioanästhesiologischen Abteilungen durchgeführten Umfrage war, die aktuelle Praxis von Neuromonitoring und Neuroprotektion zu erheben.

Methodik

Zwischen Oktober 2007 und Januar 2008 wurden hierzu Daten mithilfe eines 26 Punkte umfassenden, anonymisierten Fragebogens erhoben. Ermittelt wurden: präoperative Evaluation der hirnversorgenden Arterien, intraoperatives Neuromonitoring, zerebroprotektive Maßnahmen, Perfusionsmanagement während extrakorporaler Zirkulation, postoperative Erhebung des neurologischen Status und Aus-/Weiterbildung im zerebralen Monitoring.

Ergebnisse

55% der Fragebögen wurden mit folgenden Angaben beantwortet: präoperative Duplexsonographie der Hirngefäße in 90% der Kliniken; intraoperatives Neuromonitoring mithilfe der Elektroenzephalographie (EEG; 60%) bei Typ-A-Dissektionen (38,1%), bei elektiven Operationen an der thorakalen bzw. thorakoabdominellen Aorta (34,1% resp. 31,6%) und in der Karotischirurgie (43,2%), weiterhin Einsatz der Nahinfrarotspektroskopie (40%), Ableitung evozierter Potenziale (30%) und transkranielle Dopplersonographie (17,5%). Auch kombinierte Verfahren wurden angewandt. Während Bypass-, Klappen und minimal-invasiven Operationen erfolgt meistens kein Monitoring des Zentralnervensystems. Zur Zerebroprotektion werden die Kühlung des Patienten an Herz-Lungen-Maschine (HLM; 100%), externe Kühlung des Kopfes (65%), Gabe von Kortikosteroiden (58%), Barbituraten (50%) und Antiepileptika (10%) eingesetzt. Als neuroprotektive Anästhesieverfahren gelten Inhalationsanästhesie (32,5%; Favorit: Sevofluran 76,5%) und total intravenöse Anästhesie (20%; Favoriten: Propofol und Barbiturate mit je 46,2%). Standardmäßig kühlen 72,5% der Krankenhäuser die Patienten bei Operationen mit Herz-Kreislauf-Stillstand, 37,5% bei allen Operationen mit HLM. Unter normothermen Bedingungen entspricht in 84,6% der Kliniken der HLM-Fluss dem errechneten Herzzeitvolumen (HZV), der anzustrebende mittlere arterielle Druck (MAP) liegt bei 60–70 mmHg (43,9%) bzw. 50–60 mmHg (41,5%). Bei einer Körpertemperatur unter 18°C wird der HLM-Fluss unter das errechnete HZV gesenkt (70%), während in 27% der Kliniken normotherme Flussraten gefahren werden. Der bevorzugte MAP unter Hypothermie liegt zwischen 50 und 60 mmHg (59%). Intraoperatives Neuromonitoring wird im Narkoseprotokoll (77%) dokumentiert. Postoperativ wird der neurologische Status in 42,5% der Kliniken durch individuelle Einschätzung des Anästhesisten (77,5%) erhoben. Fortbildungen zum Thema Neuromonitoring werden in 32,5% der Kliniken regelmäßig organisiert, in 37,5% dem Arzt selbst überlassen.

Schlussfolgerung

Das kardioanästhesiologische Vorgehen in Deutschland ist im Bereich Neuromonitoring und neuroprotektive Therapie nicht standardisiert. Ein „multimodales Neuromonitoring“ wäre wünschenswert.

Abstract

Objective

The primary objective of this nationwide survey carried out in department of cardiac anesthesia in Germany was to identify current practice with regard to neuromonitoring und neuroprotection.

Methodology

The data are based on a questionnaire sent out to all departments of cardiac anesthesia in Germany between October 2007 und January 2008. The anonymized questionnaire contained 26 questions about the practice of preoperative evaluation of cerebral vessels, intra-operative use of neuromonitoring, the nature und application of cerebral protective measures, perfusion management during cardiopulmonary bypass, postoperative evaluation of neurological status, and training in the field of cerebral monitoring.

Results

Of the 80 mailed questionnaires 55% were returned and 90% of department evaluated cerebral vessels preoperatively with duplex ultrasound. The methods used for intra-operative neuromonitoring are electroencephalography (EEG, 60%) for type A dissections (38.1%), for elective surgery on the thoracic and thoraco-abdominal aorta (34.1% and 31.6%, respectively) and in carotid surgery (43.2%) near infrared spectroscopy (40%), evoked potentials (30%) and transcranial Doppler sonography (17.5%), with some centers using combined methods. In most departments the central nervous system is not subjected to monitoring during bypass surgery, heart valve surgery, or minimally invasive surgery. Cerebral protective measures used comprise patient cooling on cardio-pulmonary bypass (CPB 100%), extracorporeal cooling of the head (65%) and the administration of corticosteroids (58%), barbiturates (50%) and antiepileptic drugs (10%). Neuroprotective anesthesia consists of administering inhalation anesthetics (32.5%; sevoflurane 76.5%) and intravenous anesthesia (20%; propofol and barbiturates each accounting for 46.2%). Of the departments 72.5% cool patients as a standard procedure for surgery involving cardiovascular arrest and 37.5% during all surgery using CPB. In 84.6% of department CPB flow equals calculated cardiac output (CO) under normothermia, while the desired mean arterial pressure (MAP) varies between 60 and 70 mmHg (43.9%) and between 50 and 60 mmHg (41.5%), respectively. At body temperatures less than 18°C CPB flow is reduced below the calculated CO (70%) while 27% of departments use normothermic flow rates. The preferred MAP under hypothermia is between 50 and 60 mmHg (59%). The results of intra-operative neuromonitoring are documented on the anesthesia record (77%). In 42.5% of the departments postoperative neurological function is estimated by the anesthesiologist. Continuing education sessions pertaining to neuromonitoring are organized on a regular basis in 32.5% of the departments and in 37.5% individual physicians are responsible for their own neuromonitoring education.

Conclusion

The present survey data indicate that neuromonitoring and neuroprotective therapy during CPB is not standardized in cardiac anesthesiology departments in Germany. The systemic use of available methods to implement multimodal neuromonitoring would be desirable.

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Danksagung

Die Autoren bedanken sich bei antwortenden Herzzentren, die mit ihrer Mitarbeit diese Arbeit erst möglich gemacht haben.

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Authors and Affiliations

  1. Inselspital, Universitätsklinik für Anästhesiologie und Schmerztherapie, 3010, Bern, Schweiz

    G. Erdös D.E.A.A.

  2. Klinik für Anästhesiologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Mainz, Deutschland

    I. Tzanova

  3. Abteilung Kardioanästhesiologie, Universitätsklinikum Ulm, Ulm, Deutschland

    U. Schirmer

  4. Abteilung für Anästhesie und Intensivmedizin II, Herzzentrum, Universität Leipzig, Leipzig, Deutschland

    J. Ender

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  1. G. Erdös D.E.A.A.
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Correspondence to G. Erdös D.E.A.A..

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Erdös, G., Tzanova, I., Schirmer, U. et al. Neuromonitoring und Neuroprotektion in der Kardioanästhesie. Anaesthesist 58, 247–258 (2009). https://doi.org/10.1007/s00101-008-1485-9

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