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Intensivmedizin up2date 2015; 11(01): 33-44
DOI: 10.1055/s-0034-1391432
Allgemeine Prinzipien der Intensivmedizin
© Georg Thieme Verlag KG Stuttgart · New York

Prognose nach Herz-Kreislauf-Stillstand – ein Update

Rainer Kollmar
,
Christian Storm
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Publication Date:
12 February 2015 (online)

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Kernaussagen

  • Bei Patienten, die in der Initialphase nach der Wiederherstellung des Spontankreislaufs komatös sind, ist eine Prognoseabschätzung in den meisten Fällen sehr schwierig.

  • Ungeeignete Parameter zur Prognoseabschätzung sind die Umstände der Reanimation, anfänglicher GCS-Punktwert, Reaktion auf Schmerzreize, Hirnstammreflexe sowie die initiale Bildgebung mit CT oder MRT.

  • Die Bildgebung mit CT und MRT in der Frühphase dient vor allem der Diagnostik anderer oder komplizierender Erkrankungen nach Reanimation (z. B. Subarachnoidalblutung).

  • Es gibt bisher keine Biomarker zur sicheren Prognoseabschätzung. Allerdings korreliert die Höhe der NSE-Werte im Serum mit dem Ausmaß der Hirnschädigung. Obere Grenzwerte, die sicher eine schlechte Prognose anzeigen, sind jedoch nicht etabliert.

  • Posthypoxische Myoklonien treten nach einer Reanimation häufig auf. Sie sind ebenfalls kein sicherer Prognoseparameter.

  • Eine Temperaturkontrolle („targeted temperature management“, TTM) bzw. eine therapeutische Hypothermie erschwert die Verlässlichkeit der klinischen Untersuchung und der apparativen Diagnostik innerhalb der ersten 72 Stunden nach Reanimation.

  • Der Nachweis eines beidseitigen SEP-Verlusts innerhalb der Tage 2 – 3 nach Beginn einer hypoxischen Enzephalopathie spricht – unter der Bedingung ausreichender Erfahrung mit der Methode und sofern keine therapeutische Hypothermie durchgeführt wurde – für eine schlechte Prognose. Nach vorangegangener therapeutischer Hypothermie ist diese Sicherheit allein aufgrund des kompletten SEP-Ausfalls innerhalb von 3 Tagen nicht gegeben [17].

  • Ein Verlust der Hirnstammreflexe und ein beidseitiger SEP-Verlust (ohne Analgosedierung und Muskelrelaxation) sowie eine Aufhebung der Mark-Rinden-Grenze im kranialen CT 72 Stunden nach Beendigung der Temperaturkontrolle sprechen für eine infauste Prognose. Falls Zweifel bestehen, sollte man die Untersuchungen zu einem späteren Zeitpunkt wiederholen.

Die Literatur zu diesem Beitrag finden Sie unter http://dx.doi.org/10.1055/s-0034-1391432.

 

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