Thrombolyse beim prähospitalen Herz-Kreislauf-Stillstand

Zusammenfassung

Die Wichtigkeit einer prähospitalen Thrombolyse während der kardiopulmonalen Reanimation wird von Notfallmedizinern unterschiedlich bewertet. Während zahlreiche Studien aus einzelnen Zentren eindrucksvolle Ergebnisse berichten konnten, wurden in einer kürzlich durchgeführten, prospektiven Multizenterstudie keine signifikanten Unterschiede bezüglich der Häufigkeit von Wiedereintritt eines spontanen Kreislaufes sowie der Häufigkeit von Krankenhausaufnahme und Krankenhausentlassung festgestellt. Die Internationalen Richtlinien für Reanimation 2005 empfehlen eine Thrombolyse während der kardiopulmonalen Wiederbelebung bei Patienten mit Herzstillstand nach Pulmonalarterienembolie und als optionales therapeutisches Verfahren bei Patienten mit Kreislaufstillstand nach akutem Myokardinfarkt. Zu erwartende Effekte der Thrombolyse bei der kardiopulmonalen Reanimation sind die verbesserte Organperfusion nach Auflösung von Mikrothromben und ein damit verbundener geringerer Reoxygenierungs- und Reperfusionsschaden, der ein gutes neurologisches Ergebnis bei der Mehrzahl der CPR-Überlebenden erwarten lässt.

Abstract

Emergency physicians value the importance of thrombolysis during out-of-hospital cardiopulmonary resuscitation differently. While several studies from single centres reported impressive results, a recent prospective multicenter study could not proove significant differences in frequency of return of spontaneous circulation, hospital admission and hospital discharge. The international guidelines for resuscitation 2005 recommend thrombolysis during attempted cardiopulmonary resuscitation in patients with cardiac arrest due to presumptive pulmonary artery embolism and as a therapeutic option in patients with cardiac arrest due to presumed acute myocardial infarction. Anticipated effects of thrombolysis are improved organ perfusion, following dissolution of microthrombi, consequently reducing damage from reperfusion and reoxygenation and providing a good neurological outcome in majority of survivors.

Schlüsselwörter

Herzkreislaufstillstand - Herzkreislaufwiederbelebung - Thrombolyse - Langzeitergebnis

Key words

cardiac arrest - cardiopulmonary resuscitation - thrombolysis - outcome

Literatur

• 1 Böttiger B W. Thrombolysis during cardiopulmonary resuscitation.  Fibrinolysis & Proteolysis. 1997;  11 93-100
• 2 Böttiger B W, Bode C, Kern S, Gries A, Gust R, Glatzer R, Bauer H, Motsch J, Martin E. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial.  Lancet. 2001;  357 (9268) 1583-1585
• 3 Lederer W, Lichtenberger C, Pechlaner C, Kroesen G, Baubin M. Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest.  Resuscitation. 2001;  50 71-76
• 4 Voipio V, Kuisma M, Alaspaa A, Manttari M, Rosenberg P. Thrombolytic treatment of acute myocardial infarction after out-of-hospital cardiac arrest.  Resuscitation. 2001;  49 (3) 251-258
• 5 Fatovich D M, Dobb G J, Glugston R A. A pilot randomized trial of thrombolysis in cardiac arrest (The TICA trial).  Resuscitation. 2004;  61 309-313
• 6 Ruiz-Bailen M, Aguayo de Hoyos E, Serrano-Corcoles M C, Diaz-Castellanos M A, Ramos-Cuadra J A, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial infarction requiring cardiopulmonary resuscitation.  Intensive Care Med. 2001;  27 (6) 1050-1057
• 7 Bozeman W P, Kleiner D M, Ferguson K L. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions.  Resuscitation. 2006;  69 (3) 399-406
• 8 Stadlbauer K H, Krismer A C, Arntz H R, Mayr V D, Lienhart H G, Böttiger B W, Jahn B, Lindner K H, Wenzel V. Effects of Thrombolysis During Out-of-Hosapital Cardiopulmonary Resuscitation.  Am J Cardiol. 2006;  97 (3) 305-308
• 9 Verstraete M, Miller G AH, Bounameaux H, Charbonnier B, Colle J P, Lecorf G, Marbet G A, Mombaerts P, Olsson C G. Intravenous and intrapulmonary recombinant tissue-type plasminogen activator in the treatment of acute massive pulmonary embolism.  Circulation. 1988;  77 353-360
• 10 Janata K, Holzer M, Kurkciyan I, Losert H, Riedmuller E, Pikula B, Laggner A N, Laczika K. Major bleeding complications in cardiopulmonary resuscitation: the place of thrombolytic therapy in cardiac arrest due to massive pulmonary embolism.  Resuscitation. 2003;  57 (1) 49-55
• 11 Böttiger B W, Motsch J, Bohrer H, Boker T, Aulmann M, Nawroth P P, Martin E. Activation of blood coagulation after cardiac arrest is not balanced adequately by activation of endogenous fibrinolysis.  Circulation. 1995;  92 (9) 2572-2578
• 12 Bode C, Nordt T K, Peter K, Smalling R W, Runge M S, Kubler W. Patency trials with reteplase (r-PA): what do they tell us?.  Am J Cardiol. 1996;  78 (12A) 16-19
• 13 Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, Laggner A N. Thrombolytic therapy after cardiac arrest and its effect on neurological outcome.  Resuscitation. 2002;  52 (1) 63-69
• 14 Lederer W, Lichtenberger C, Pechlaner C, Kinzl J F, Kroesen G, Baubin M. Out-of-hospital cardiac arrest: Long-term survival and neurological outcome of patients who received recombinant tissue plasminogen activator during cardiopulmonary resuscitation.  Resuscitation. 2004;  61 (2) 123-129
• 15 Lederer W, Lichtenberger C, Pechlaner C, Kroesen G, Baubin M. Role of thrombolysis in resuscitation.  Lancet. 2001;  358 (9290) 1372
• 16 Thrombolysis in Cardiac Arrest Studie (TROICA). Inoffizielle Datenvorstellung. Barcelona; 2006
• 17 International Liaison Committee on Resuscitation (ILCOR) . Part 4: Advanced Life Support.  Resuscitation. 2005;  67 213-247
• 18 Hartveit F, Halleraker B. Intravascular changes in kidneys and lungs after external cardiac massage: a preliminary report.  J Pathol. 1970;  102 (1) 54-58
• 19 Gando S, Kameue T, Nanzaki S, Nakanishi Y. Massive fibrin formation with consecutive impairment of fibrinolysis in patients with out-of-hospital cardiac arrest.  Thrombosis and haemostasis. 1997;  77 78-82
• 20 Fischer M, Böttiger B W, Popov-Cenic S, Hossmann K A. Thrombolysis using plasminogen activator and heparin reduces cerebral no-reflow after resuscitation from cardiac arrest: an experimental study in the cat.  Intensive Care Med. 1996;  22 1214-1223
• 21 Van de Werf F J. The ideal fibrinolytic: Can drug design improve clinical results?.  Europ Heart J. 1999;  20 1452-1458
• 22 Mousa S A, Bozarth J, Barrett J S. Pharmacodynamic properties of the low molecular weight heparin, tinzaparin: effect of molecular weight distribution on plasma tissue factor pathway inhibitor in healthy human subjects.  J Clin Pharmacol. 2003;  43 (7) 727-734
• 23 Gurfinkel E P, Altman R, Scazziota A, Heguilen R, Mautner B. Fast platelet suppression by lysine acetylsalicylate in chronic stable coronary patients. Potential clinical impact over regular aspirin for coronary syndromes.  Clin Cardiol. 2000;  23 (9) 697-700
• 24 Holmberg M, Holmberg S, Herlitz J. Incidence, duration and survival of ventricular fibrillation in out-of-hospital cardiac arrest patients in Sweden.  Resuscitation. 2000;  44 (1) 7-17
• 25 Wik L, Hansen T B, Fylling F, Steen T, Vaagenes P, Auestad B H, Steen P A. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial.  JAMA. 2003;  289 (11) 1389-1395
• 26 Lederer W, Lichtenberger C, Kroesen G, Baubin M. Thrombolytic therapy in sustained ventricular fibrillation.  Acta Anaesthesiologica Scand. 2001;  45 (8) 1054
• 27 Zaugg C. Current Concepts on Ventricular Fibrillation: A Vicious Circle of Cardiomyocyte Calcium Overload in the Initiation, Maintenance, and Termination of Ventricular Fibrillation.  Indian Pacing and Electrophysiology Journal. 2004;  4 (2) 85-92
• 28 Kojima Y, Urano T, Kojima K, Serizawa K, Takada Y, Takada A. The significant enhancement of fibrinolysis by calcium ion in a cell free system: the shortening of euglobulin clot lysis time by calcium ion.  Thromb Haemost. 1994;  72 (1) 113-118
• 29 Lederer W, Schlimp C J, Niederklapfer T, Amann A. Altered electrical activity of fibrillation process following thrombolytic therapy in out-of-hospital cardiac arrest patients with sustained ventricular fibrillation.  Med Hypotheses. 2006;  67 (2) 333-335
• 30 Wang X, Tsuji K, Lee S R, Ning M, Furie K L, Buchan A M, Lo E H. Mechanisms of hemorrhagic transformation after tissue plasminogen activator reperfusion therapy for ischemic stroke.  Stroke. 2004;  35 2726-2730
• 31 Heyman S N, Hanna Z, Nassar T, Shina A, Akkawi S, Goldfarb M, Rosen S, Higazi A A. The fibrinolytic system attenuates vascular tone: effects of tissue plasminogen activator (tPA) and aminocaproic acid on renal microcirculation.  Br J Pharmacol. 2004;  141 (6) 971-978
• 32 Lederer W, Lichtenberger C, Pechlaner C, Kroesen G, Baubin M. Tissue Plasminogen Activator in out-of-hospital Cardiac Arrest with Asystole.  The Internet Journal of Emergency Medicine. 2003;  1 (2) http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijem/vol1n2/rtpa.xml
• 33 Abu-Laban R B, Christenson J M, Innes G D, van Beek C A, Wanger K P, McKnight R D, MacPhail I A, Puskaric J, Sadowski R P, Singer J, Schechter M T, Wood V M. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity.  N Engl J Med. 2002;  346 (20) 1522-1528
• 34 Safar P. Resuscitation from clinical death: pathophysiologic limits and therapeutic potentials.  Crit Care Med. 1988;  16 (10) 923-941
• 35 Gando S, Nanzaki S, Morimoto Y, Kobayashi S, Kemmotsu O. Out-of-hospital cardiac arrest increases soluble vascular endodethial adhesion molecules and neutrophil elastase associated with endothelial injury.  Intensive Care Med. 2000;  26 38-44
• 37 Hoffmann J J, Bonier J J, Melman P G, Bartholomeus I. Blood viscosity during thrombolytic therapy with anistreplase in acute myocardial infarction.  Am J Cardiol. 1993;  71 (1) 14-18
• 38 Krapohl B, Siemionow M, Zins J. Effect of tissue-plasminogen activator on leukocyte-endothelial interactions at the microcirculatory level.  Plastic & Reconstructive Surgery. 1998;  102 (7) 2388-2394
• 39 Stringer K A, Hybertson B M, Cho O J, Cohen Z, Repine J E. Tissue plasminogen activator (tPA) inhibits interleukin-1 induced acute lung leak.  Free Radiacal Biology & Medicine. 1998;  25 (2) 184-188
• 40 Roelofs J J, Rouschop K M, Leemans J C, Claessen N, de Boer A M, Frederiks W M, Lijnen H R, Weening J J, Florquin S. Tissue-type plasminogen activator modulates inflammatory responses and renal function in ischemia reperfusion injury.  J Am Soc Nephrol. 2006;  17 (1) 131-140
• 41 Schoots I G, Levi M, van Vliet A K, Declerck P J, Maas A M, van Gulik T M. Enhancement of endogenous fibrinolysis does not reduce local fibrin deposition, but modulates inflammation upon intestinal ischemia and reperfusion.  Thromb Haemost. 2004;  91 (3) 497-505
• 42 Audebert H J, Rott M M, Eck T, Haberl R L. Systemic inflammatory response depends on initial stroke severity but is attenuated by successful thrombolysis.  Stroke. 2004;  35 (9) 2128-2133
• 43 Merlini P A, Cugno M, Rossi M L, Agricola P, Repetto A, Fetiveau R, Diotallevi P, Canosi U, Mannucci P M, Ardissino D. Activation of the contact system and inflammation after thrombolytic therapy in patients with acute myocardial infarction.  Am J Cardiol. 2004;  93 (7) 822-825
• 44 Kouwenhoven W B, Jude J R, Knickerbocker G G. Closed-chest cardiac Massage.  JAMA. 1960;  173 1064-1067
• 45 Valenzuela T D, Roe D J, Cretin S, Spaite D W, Larsen M P. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model.  Circulation. 1997;  96 (10) 3308-3313
• 46 Nagao K, Hayashi N, Kanmatsuse K, Arima K, Ohtsuki J, Kikushima K, Watanabe I. Cardiopulmonary cerebral resuscitation using emergency cardiopulmonary bypass, coronary reperfusion therapy and mild hypothermia in patients with cardiac arrest outside the hospital.  J Am Coll Cardiol. 2000;  36 (3) 776-783
• 47 Safar P, Behringer W, Boettiger B W, Sterz F. Cerebral resuscitation potentials for cardiac arrest.  Crit Care Med. 2000;  30 (4 Suppl) 140-144