-
[show abstract]
[hide abstract]
ABSTRACT: Die Entwicklung der kardiopulmonalen Reanimation und die Fortschritte der Intensivmedizin ermöglichen, dass Herz-Kreislauf-Stillstände
überlebt werden können. Allerdings erreichen nur 10–30% aller initial erfolgreich reanimierten Patienten einen Zustand ohne
schwere neurologische Defizite. Aus ethischen und sozioökonomischen Gründen ist es daher von Bedeutung, früh eine zuverlässige
Aussage zur Prognose einzelner Patienten zu treffen. Es gibt keine zuverlässigen Parameter für die Vorhersage eines günstigen
klinischen Outcomes. Sofern Anamnese und Klinik für einen schweren hypoxischen Hirnschaden sprechen, kortikale somatosensorisch
evozierte Potenziale (SEP) ausgefallen sind und Werte der neuronspezifischen Enolase (NSE) >33–65μg/l gemessen werden, kann
ein zukünftiges Wiedererlangen des Bewusstseins als ausgeschlossen gelten. Das gleiche gilt, wenn die Bildgebung schwere hypoxämische
Veränderungen zeigt oder am ersten Tag ein Status myoclonicus auftritt. Insgesamt ist die Prognose bei Patienten mit zerebraler
Anoxie und kardiopulmonaler Reanimation, die im Verlauf zunächst bewusstlos bleiben, überwiegend ungünstig. Initiale Hypothermiebehandlung
über 24h wird empfohlen.
The developments of cardiopulmonary resuscitation and intensive care medicine have made possible survival after cardiac arrest.
However, only 10–30% of patients with initially successful resuscitation later reach a state without severe neurological impairment.
Ethical and socioeconomic reasons therefore make early prognosis important for certain patients. There are no reliable parameters
for predictions of good clinical outcome. If clinical information is consistent with severe hypoxic brain damage, cortical
somatosensory evoked potentials are absent, and neuron-specific enolase values exceed 33–65μg/l, recovery of consciousness
can be excluded. The same result can be predicted if brain imaging shows severe hypoxemic changes or if a myoclonic status
occurs on the first day. In summary, the prognosis in patients with cerebral anoxy and cardiopulmonary resuscitation remains
poor. Treatment with hypothermia for 24h is recommended.
Der Nervenarzt 05/2012; 78(8):937-943. · 0.68 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The microcirculatory status depicts an indicator of organ perfusion in hemodynamic shock. Distribution pattern of microcirculatory disturbances reflects the underlying cause of shock: In septic shock, organ perfusion is severely impaired via arteriolo-venous shunting with shutting up small vessel perfusion; however, cardiogenic shock is characterized by a global impairment of microcirculation, involving all vascular beds. Hence, a differentiated evaluation of microcirculatory disturbances not only supports an early diagnosis of an imminent multiorgan dysfunction syndrome (MODS), but also allows a more accurate evaluation of severity of hemodynamic compromise in critical care medicine. Bedside sidestream darkfield (SDF) technique offers the opportunity to describe the microcirculatory status quo semiquantitatively and to evaluate the effect of novel therapeutic approaches on microcirculation. Further technical improvements of this technique may open new fields of diagnostic and therapeutic applications in intensive care medicine by supporting an early diagnosing of MODS, evaluating prognosis, and optimizing therapeutic measures .
DMW - Deutsche Medizinische Wochenschrift 05/2011; 136(19):1009-13. · 0.53 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We investigated whether there are differences in autonomic cardiovascular regulation in resuscitated patients undergoing therapeutic hypothermia (TH) in relation to the clinical outcome.
Between 2005 and 2007, 18 consecutive resuscitated patients were enrolled. ECG and blood pressure data were recorded for 48 h during hypothermia and warming up to a body core temperature of 36°C. Autonomic regulation was assessed by applying time, frequency, and non-linear dynamics domain methods from heart rate and blood pressure variability (HRV/BPV) analyses.
Nine patients survived with good neurological recovery, and nine patients died during the ICU stay. In both groups, we found a decreased HRV presented by standard deviation of R-R intervals (sdNN) below 50 ms(2) at each time of measurement. Immediately after recovery to a body core temperature of 36°C, a significant higher HRV was found in survivors compared to non-survivors by means of indices sdNN (40.2 ± 19.5 vs. 10.9 ± 4.1 ms(2), P = 0.01), R-R intervals distribution histogram [shannon] (3.7 ± 0.6 vs. 2.2 ± 0.4, P = 0.008), very low frequency band [VLF] (152.2 ± 99.3 vs. 3.4 ± 1.9, P = 0.001) and the variance of the time series of R-R intervals [Wsdvar] (1.16 ± 0.52 vs. 0.29 ± 0.25, P = 0.02) . A decreased spontaneous BPV was found only among survivors comparing blood pressure characteristics within stable hypothermia to the initial state before hypothermia.
Resuscitated patients show a significantly reduced HRV before, during and after TH. Compared to survivors, the non-survivors show a further and significantly decrease of HRV immediately after hypothermia.
Clinical Research in Cardiology 04/2011; 100(9):797-805. · 2.95 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The developments of cardiopulmonary resuscitation and intensive care medicine have made possible survival after cardiac arrest. However, only 10-30% of patients with initially successful resuscitation later reach a state without severe neurological impairment. Ethical and socioeconomic reasons therefore make early prognosis important for certain patients. There are no reliable parameters for predictions of good clinical outcome. If clinical information is consistent with severe hypoxic brain damage, cortical somatosensory evoked potentials are absent, and neuron-specific enolase values exceed 33-65 microg/l, recovery of consciousness can be excluded. The same result can be predicted if brain imaging shows severe hypoxemic changes or if a myoclonic status occurs on the first day. In summary, the prognosis in patients with cerebral anoxy and cardiopulmonary resuscitation remains poor. Treatment with hypothermia for 24 h is recommended.
Der Nervenarzt 09/2007; 78(8):937-43. · 0.68 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A 24-year-old female with a history of epileptic seizures was admitted after prolonged cardiac resuscitation. The clinical course together with additional examinations led to the diagnosis of severe hypoxic cerebral damage, with poor prognosis for neurological outcome. In her initial ECG, as in the ECGs of several family members, QT prolongation was diagnosed. Meticulous history taking and ensuing genetic analysis led to the diagnosis of familial long QT syndrome (LQTS) with a mutation in the LQT-2 gene (HERG). In retrospect, the previous seizure episodes have to be considered cardiac syncopes. Two family members had previously died suddenly, and ECG and genetic analysis revealed that a total of eight family members were affected. These relatives were prophylactically treated with beta blockers or supplied with automated implantable cardioverter defibrillating devices. The literature concerning LQTS, diagnosis and prognosis of cerebral hypoxic damage, and differentiation between seizures and cardiac syncopes is discussed.
Der Nervenarzt 11/2006; 77(10):1210-7. · 0.68 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Eine 24-jhrige Patientin mit bekannter Grand-Mal-Epilepsie wurde nach prolongierter Reanimation eingewiesen. Klinik und Zusatzdiagnostik erbrachten einen schweren hypoxischen Hirnschaden mit Abschtzung einer schlechten Prognose hinsichtlich des neurologischen Langzeitergebnisses. Diese besttigte sich im weiteren Verlauf ber zwei Jahre. Bei verlngerter QT-Zeit im EKG und genauer Anamneseerhebung mussten die vormaligen Ereignisse als kardiale Synkopen bei Long-QT-Syndrom (LQTS) gedeutet werden. Die in solchen Fllen zwingend notwendige Anamneseerhebung, EKG-Registrierung und molekulargenetische Analyse bei den Familienmitgliedern ergab die Diagnose eines familiren LQTS in 8 Fllen, in 2 Fllen bereits mit bis dahin ungeklrtem pltzlichem Herztod. Zur Prophylaxe weiterer Ereignisse wurden betroffene Familienangehrige mit -Blockern behandelt bzw. mit AICD-Aggregaten (automatischer implantierbarer Kardioverter-Defibrillator) versorgt. Die aktuelle Literatur hinsichtlich des LQTS, der Differenzierung der kardialen Synkope zur Epilepsie sowie der Einschtzung der Prognose eines hypoxischen Hirnschadens werden diskutiert.A 24-year-old female with a history of epileptic seizures was admitted after prolonged cardiac resuscitation. The clinical course together with additional examinations led to the diagnosis of severe hypoxic cerebral damage, with poor prognosis for neurological outcome. In her initial ECG, as in the ECGs of several family members, QT prolongation was diagnosed. Meticulous history taking and ensuing genetic analysis led to the diagnosis of familial long QT syndrome (LQTS) with a mutation in the LQT-2 gene (HERG). In retrospect, the previous seizure episodes have to be considered cardiac syncopes. Two family members had previously died suddenly, and ECG and genetic analysis revealed that a total of eight family members were affected. These relatives were prophylactically treated with beta blockers or supplied with automated implantable cardioverter defibrillating devices. The literature concerning LQTS, diagnosis and prognosis of cerebral hypoxic damage, and differentiation between seizures and cardiac syncopes is discussed.
Der Nervenarzt 09/2006; 77(10):1210-1217. · 0.68 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Patienten, die bei einem Herz-Kreislaufstillstand primr
erfolgreich reanimiert werden, haben im weiteren Verlauf ein
hohes Risiko zu versterben bzw. ein schweres neurologisches
Defizit zu entwickeln, bis hin zum apallischen Syndrom. Wir
untersuchten von 1998 bis 2002 bei 97 Patienten den
prognostischen Vorhersagewert epidemiologischer sowie
klinisch-neurologischer Parameter und der beiden Neuroproteine
NSE und S 100.Ergebnisse52,6% der Reanimierten verstarben, 28,8% berlebten mit
migem bzw. ohne neurologisches Defizit. 39% der
Langzeitberlebenden entwickelten ein appallisches Syndrom. Das
Fortbestehen einer komatsen Bewusstseinslage ber 48 h nach CPR
und ein GCS von < 6 Punkten waren mit einem 60fach hherem
Risiko fr eine schlechte neurologische Prognose verbunden. Das
berschreiten einer NSE-Serumkonzentration von 65 ng/ml bzw.
einer S 100-Serumkonzentration von 1,5 g/l erhhten das Risiko
fr eine schlechte Prognose um das 16,8- bzw. 12,6fache.SchlussfolgerungenWir empfehlen fr die individuelle Prognoseermittlung
komatser berlebender nach CPR die mindestens einmal tgliche
klinischneurologische Untersuchung mit Erhebung des
GCS-Punktewertes und die einmal tgliche Bestimmung der
Serumkonzentration von NSE oder S 100. Die Kombination von
GCS-Punktewert und den Serumkonzentrationen von NSE und S 100
erhht den Vorhersagewert gegenber den Einzelparametern.BackgroundPatients successfully resuscitated from cardiac arrest are
at high risk of increased mortality and their longterm outcome
is often complicated by developing severe neurological disorders
up to a persistant vegetative state. We investigated the
prognostic value of some epidemiological and clinical markers
and two neuroproteins, neuron-specific enolase (NSE) and S 100
protein (S 100), in 97 patients undergoing cardiopulmonary
resuscitation after nontraumatic cardiac arrest between 1998 and
2002.Results52.6% of the patients died, 28.8% survived with moderate
or without neurological disorders, and 39% with persistent
vegetative state. The persistence of unconsciousness over 48
hours after CPR and a Glasgow Coma Score (GCS) of less than 6
points after 72 hours predicted a 60-fold higher risk of poor
neurological outcome. A serum NSE level of more than 65 ng/ml
and a serum S 100 level of more than 1.5 g/l were found to be
predictors of death and not regaining consciousness, with a high
specificity (96%) and a positive predictive value of 97%. To
exceed these limits, increases the risk of poor neurological
outcome and death by 16.8- and 12.6-fold.ConclusionsWe recommend in addition to the day-to-day clinical
examination with enquiry of the Glasgow Coma Score, the
measurement of the serum levels of NSE or S 100 protein over a
fiveday period as markers with a high predictive value for poor
cerebral outcome. The combination of GCS and the serum levels of
NSE or S 100 protein at 72 hours after CPR permit a more
reliable prediction of outcome in postanoxic coma than clinical
examination and serum markers alone.
Intensivmedizin + Notfallmedizin 03/2004; 41(3):171-180.
