Zusammenfassung
Hintergrund
Die Sterblichkeit bei Patienten mit kardiogenem Schock nach Herzstillstand bleibt trotz der Fortschritte bei den Wiederbelebungsmaßnahmen und der frühen Revaskularisierung sehr hoch. Gegenwärtig wird der Einsatz der milden therapeutischen Hypothermie (MTH) zur Verbesserung des Überlebens und neurologischen Outcomes bei diesem Patientenkollektiv neu diskutiert.
Fragestellung
Detektion von Einflussfaktoren auf Morbidität und Mortalität bei Patienten nach präklinischer Reanimation [„out-of-hospital cardiac arrest“ (OHCA)] unter MTH im kardiogenen Schock.
Methodik
Retrospektive Analyse von 80 konsekutiven Patienten (mittleres Alter 60 ± 3,2 Jahre) im kardiogenen Schock. Alle Patienten wurden mithilfe eines endovaskulären Kühlkatheters für 24 h gekühlt. Das neurologische Outcome der Patienten wurde 2 Monate nach OHCA basierend auf der Glasgow-Pittsburgh Cerebral Performance Category (CPC) erhoben und mit verschiedenen Blutwerten korreliert.
Ergebnisse
Zwei Monate nach Indexereignis zeigten 31 Patienten (39 %) eine gute neurologische Erholung (CPC 1–2), 20 Patienten (25 %) wiesen ein schlechtes neurologisches Outcome (CPC 3–4) auf. 29 Patienten (36 %) waren verstorben (CPC 5). Bei den Patienten mit schlechtem neurologischem Outcome fanden sich signifikant höhere Laktat-, Kreatinin- und Harnstoffwerte. Zudem kam es bei diesen Patienten, im Gegensatz zu den Patienten mit gutem neurologischem Outcome, zu einem kontinuierlichen Anstieg der neuronenspezifischen Enolase (NSE; ∆ NSE, Ankunft zu Tag 1, CPC 1–2: − 10,6 ± 3 µg/l; CPC 3–5: 33 ± 12 µg/l; p = 0,02).
Schlussfolgerung
Der Verlauf von Kreatinin, Harnstoff und NSE im Serum innerhalb der ersten 72 h nach OHCA könnte bei Patienten unter MTH wertvolle ergänzende Informationen zur frühzeitigen Beurteilung der neurologischen Prognose bieten.
Abstract
Background
The mortality in patients with cardiogenic shock after out-of-hospital cardiac arrest (OHCA) remains high despite advances in resuscitation and early revascularization strategies. The use of mild therapeutic hypothermia (MTH) for improvement of survival and neurological outcome in patients with cardiogenic shock is currently subject to renewed discussion.
Objective
The aim of this study was the detection of risk factors for mortality and morbidity in patients under MTH in cardiogenic shock following preclinical resuscitation for OHCA.
Methods
A total of 80 consecutive patients in cardiogenic shock after successful resuscitation (mean age 60 ± 3.2 years) treated with MTH were retrospectively analyzed. Patients were cooled to 33 °C for 24 h using an endovascular cooling device. Neurological outcome was assessed after 2 months based on the Glasgow-Pittsburgh cerebral performance category (CPC) and correlated with various blood parameter values.
Results
After 2 months 31 patients (39 %) showed a good neurological recovery with CPC scores of 1–2, 20 patients (25 %) had a poor neurological outcome with CPC scores of 3–4 and 29 (36 %) patients enrolled in the trial died (CPC 5). Patients with a poor outcome showed significantly higher mean serum levels for lactate, creatinine and urea. In addition, these patients showed a continuous increase of serum neuron-specific enolase (NSE) values in contrast to patients with a good outcome (∆ NSE from admission to day 1, CPC 1 and 2: − 10.6 ± 3 µg/l and CPC 3–5: 33 ± 12 µg/l, p = 0.02).
Conclusion
Changes in the course of serum creatinine, urea and NSE levels within the first 72 h after OHCA could provide valuable additional information for the early assessment of the neurological prognosis in patients treated with MTH.
Literatur
Annborn M, Bro-Jeppesen J, Nielsen N et al; TTM-trial investigators (2014) The association of targeted temperature management at 33 and 36 °C with outcome in patients with moderate shock on admission after out-of-hospital cardiac arrest: a post hoc analysis of the Target Temperature Management trial. Intensive Care Med 40:1210–1219
Bernard SA, Gray TW, Buist MD et al (2002) Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 346:557–563
Cummins RO, Chamberlain DA, Abramson NS et al (1991) Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. Task Force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Ann Emerg Med 20(8):861–874
De Backer D, Biston P, Devriendt J et al (2010) Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 362:779–789
Flesch MJ, Hagemeister J, Berger HJ et al (2008) Implementation of guidelines for the treatment of acute ST-elevation myocardial infarction: the Cologne Infarkt Model Registry. Circ Cardiovasc Intervent 1:95–102
Fugate JE, Wijdicks EF, Mandrekar J, Claassen DO et al (2010) Predictors of neurologic outcome in hypothermia after cardiac arrest. Ann Neurol 68(6):907–914
Hasper D, von Haehling S, Storm C et al (2009) Changes in serum creatinine in the first 24 h after cardiac arrest indicate prognosis: an observational cohort study. Crit Care 13(5):R168
Herff H, Schneider A, Schröder D, Wetsch W, Böttiger BW (2015) Therapeutic hypothermia in 2015: influence of the TTM study on the intensive care procedure after cardiac arrest. Med Klin Intensivmed Notfmed (im Druck)
Hochman JS, Sleeper LA, Webb JG et al (1999) Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. N Engl J Med 341:625–634
Hovdenes J, Laake JH, Aaberge L et al (2007) Therapeutic hypothermia after out-of-hospital cardiac arrest: experiences with patients treated with percutaneous coronary intervention and cardiogenic shock. Acta Anaesthesiol Scand 51(2):137–142
Huntgeburth M, Adler C, Rosenkranz S et al (2014) Changes in neuron-specific enolase are more suitable than its absolute serum levels for the prediction of neurologic outcome in hypothermia-treated patients with out-of-hospital cardiac arrest. Neurocrit Care 20(3):358–366
Kim YM, Yim HW, Jeong SH et al (2012) Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms? A systematic review and meta-analysis of randomized and non-randomized studies. Resuscitation 83(2):188–196
Lemiale V, Dumas F, Mongardon N et al (2013) Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort. Intensive Care Med 39(11):1972–1980
Mader TJ, Nathanson BH, Millay S et al (2012) Out-of-hospital cardiac arrest outcomes stratified by rhythm analysis. Resuscitation 83(11):1358–1362
Nielsen N, Wetterslev J, Friberg H et al (2014) TTM Trial Steering Group. Targeted temperature management after cardiac arrest. N Engl J Med 370(14):1360
Nolan JP, Soar J, Zideman DA et al (2010) European Resuscitation Council guidelines for resuscitation 2010 section 1. Executive summary. Resuscitation 81(10):1219–1276
Nolan JP, Hazinski MF, Aickin R et al (2015) International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 1: executive summary. Resuscitation 95:e1–e31
Shinozaki K, Oda S, Sadahiro T (2009) Serum s-100b is superior to neuron-specific enolase as an early prognostic biomarker for neurological outcome following cardiopulmonary resuscitation. Resuscitation 80(8):870–875
Skulec R, Kovarnik T, Dostalova G et al (2008) Induction of mild hypothermia in cardiac arrest survivors presenting with cardiogenic shock syndrome. Acta Anaesthesiol Scand 52(2):188–194
Testori C, Sterz F, Holzer M et al (2012) The beneficial effect of mild therapeutic hypothermia depends on the time of complete circulatory standstill in patients with cardiac arrest. Resuscitation 83(5):596–601
The Hypothermia after Cardiac Arrest Study Group (2002) Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 346:549–556
Trzeciak S, Jones AE, Kilgannon JH et al (2009) Significance of arterial hypotension after resuscitation from cardiac arrest. Crit Care Med 37(11):2895–2903
Werdan K, Ruß M, Buerke M et al (2012) Deutsch-österreichische S3-Leitlinie „Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie“. Dtsch Arztebl Int 109(19):343–351
Wijdicks EF, Hijdra A, Young GB et al (2006) Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 67(2):203–210
Wnent J, Bohn A, Seewald S et al (2013) Laienreanimation: Einfluss von Erster Hilfe auf das Überleben. Anästhesiol Intensivmed Notfallmed Schmerzther 48:562–565
Zandbergen EG, Hijdra A, Koelman JH et al (2006) Prediction of poor outcome within the first 3 days of postanoxic coma. Neurology 66(1):62–68
Zobel C, Adler C, Kranz A et al (2012) Mild therapeutic hypothermia in cardiogenic shock syndrome. Crit Care Med 40(6):1715–1723
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
C. Adler, R. Pfister, S. Baldus und H. Reuter geben an, dass kein Interessenkonflikt besteht.
Die Datenerhebung wurde mit Zustimmung der zuständigen Ethik-Kommission, im Einklang mit nationalem Recht sowie gemäß der Deklaration von Helsinki von 1975 (in der aktuellen, überarbeiteten Fassung) durchgeführt.
Additional information
Redaktion
M. Buerke, Siegen
Rights and permissions
About this article
Cite this article
Adler, C., Pfister, R., Baldus, S. et al. Milde therapeutische Hypothermie im kardiogenen Schock. Med Klin Intensivmed Notfmed 112, 24–29 (2017). https://doi.org/10.1007/s00063-015-0122-z
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00063-015-0122-z