Prognose nach Herz-Kreislauf-Stillstand – ein Update

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.

• Literatur

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