Mild therapeutic hypothermia

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The targeted temperature management (MTH) is the state of the lowered as a medical procedure on 32 to 34 ° C body temperature ( hypothermia ). It has been included in the international guidelines for resuscitation of adult patients, contributes to increasing the survival rate and improving the neurological condition after successful resuscitation and should be initiated as soon as possible. It is achieved through targeted temperature management .

Unconscious patients who have been successfully resuscitated after cardiac arrest due to ventricular fibrillation should, according to the ILCOR recommendation of July 8, 2003, be cooled down to 32 to 34 ° C core body temperature for 12 to 24 hours. After the 24 hours, they should be reheated slowly, at a maximum of 0.25–0.5 ° C per hour. The metabolism and oxygen consumption of the tissue are reduced, and hypoxic tissue damage, especially of the brain, is prevented. The low temperature may also reduce the concentration of free oxygen radicals , which would otherwise cause further cell death in the damaged tissue. The heart rate slows down, the so-called QRS complexes on the electrocardiogram widen, the potassium level in the blood drops, urine production increases and the blood sugar level can rise. In addition, a reversible dilation of the pupil can occur; Wide, light-rigid pupils do not have to be signs of severe brain damage in a hypothermic patient. Cooling to much lower temperatures is known as deep hypothermia , and this can lead to life-threatening complications such as cardiac arrhythmias , metabolic disorders and cardiac arrest .

Another area of ​​application of MTH is the care of newborns with asphyxia during the birth process. The therapeutic hypothermia can not only reduce the mortality of children, but above all the neurological outcome can be improved. Patients with increased intracranial pressure or a heart attack show a better outcome , and patients after a stroke even a significantly better outcome if they are treated with mild therapeutic hypothermia.

In patients with multiple trauma , head trauma or massive blood loss , mild therapeutic hypothermia is controversial, since the complications, especially susceptibility to infection and wound healing disorders, usually predominate.

Cooling techniques

Superficial cooling

Superficial cooling with cooling ceilings, cooling tents, cold washing or ice packs has disadvantages: all of these processes can only be controlled to a limited extent. There can be significant problems, especially with rewarming. The targeted rewarming in 0.1 to 0.5 ° C steps (see guidelines) cannot be controlled. The target temperature can hardly be reached in overweight patients.

Invasive cooling

  • The cooling with special cooling catheters with up to 4 cooling balloons offers good controllability during cooling and especially during heating; fever management is possible.
  • The cooling can also be provided extracorporeally, i.e. outside the body (e.g. dialysis , heater-cooler units HCU, heart-lung machine ).
  • Cooling by means of cold infusion should only be used initially and combined with surface cooling ; there is a risk of reperfusion damage with infusion alone and that of volume loading and pulmonary edema.

Studies on effectiveness

A study from the USA showed no benefit of the invasive administration of chilled saline solution alone before arrival at the clinic. The problem was that if hypothermia was induced early, the administration of chilled saline alone led to more frequent cardiac arrests and pulmonary edema . The infusion with one liter of chilled saline solution showed a cooling of 0.75 ° C with an unfavorable rewarming of 0.5 ° C to ultimately 0.25 ° C cooling within one hour in patients in the iCOOL3 study (NCT01584180, DGN Congress Poster 2012). This harmful rewarming ( reperfusion damage ) is two to four times faster than indicated in the guidelines. If surface cooling methods are used in addition to chilled saline solutions, the overall result is steady cooling without intermediate reheating (iCOOL1 study, NCT01573117, Crit Care. 2014).

Nielsen's TTM study from November 2013 showed that active cooling to 36 ° C is already beneficial after a cardiac arrest. The Scandinavian TTM study, however, had a lay resuscitation rate of 73 percent, almost four times more than in Germany. A median of just 60 seconds passed before resuscitation, which reduces the damage. Medical societies such as the European Resuscitation Council recommend, with reference to the new studies, to continue to cool regularly to 32 to 34 ° C. An evaluation of the INTCAR database ( international cardiac arrest registry ) from Sendelbach showed in 2012:

  • Every five minutes delay in initiating mild therapeutic hypothermia (MTH) means an increase in poor neurological outcome of 8%.
  • A 30-minute delay in reaching the target temperature of 32 to 34 ° C increases the rate of poor neurological outcome by 17%.
  • On average, clinics need 94 minutes to initiate MTH and 309 minutes to reach the target temperature.

literature

  • S. Sendelbach u. a .: Effects of variation in temperature management on cerebral performance category scores in patients who received therapeutic hypothermia post cardiac arrest . In: Resuscitation . 2012 Jul, 83 (7), pp. 829-834, doi: 10.1016 / j.resuscitation.2011.12.026 , PMID 22230942 .
  • Key points of the German Medical Association for resuscitation (PDF) 2010,
  • Brüx, Girbes, Polderman: Controlled and moderate hypothermia . In: Der Anästhesist , 03/2005, 54, pp. 255–244. Springer Medizin Verlag.
  • Popp, Sterz, Böttiger: Therapeutic mild hypothermia after cardiovascular arrest . In: Der Anästhesist , 02/2005, 54, pp. 96-106. Springer Medizin Verlag.
  • SA Bernard, TW Gray, MD Buist, BM Jones, W Silvester, G Gutteridge, K. Smith: Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. In: N Engl J Med , 2002 Feb 21, 346 (8), pp. 557-556, PMID 11856794
  • JP Nolan, PT Morley: Therapeutic Hypothermia After Cardiac Arrest: An Advisory Statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. In: Circulation , 2003, 108, pp. 118–121 (PDF; 317 kB)
  • Hypothermia after Cardiac Arrest Study Group: Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. In: N Engl J Med. , 2002 Feb 21, 346 (8), pp. 549-556, PMID 11856793
  • K. Flemming, E. Ziegs, C. Diewok, R. Gildemeister, C. Wunderlich, G. Simonis, RH Strasser: Comparison of internal and external cooling for the induction of hypothermia in patients after resuscitation . Technical University Dresden, Heart Center Dresden University Clinic, Medical Clinic / Cardiology
  • Marlene Fischer, Anelia Dietmann, Peter Lackner, Ronny Beer, Raimund Helbok, Bettina Pfausler, Markus Reindl, Erich Schmutzhard, Gregor Broessner: Endovascular cooling and endothelial activation in patients with hemorrhagic insults . In: Neurocritical Care Society Neurocrit Care , doi: 10.1007 / s12028-011-9521-z
  • CD Deakin, JP Nolan, J. Soar, K. Sunde, RW Koster, GD Perkins, GB Smith: Advanced resuscitation measures for adults ("advanced life support") . Section 4 of the European Resuscitation Council Guidelines for Resuscitation 2010. In: Emergency Rettungsmed , 2010, 13, pp. 559–620 doi: 10.1007 / s10049-010-1370-3 , European Resuscitation Council
  • Øystein Tønte, Tomas Drægni, Arild Mangschau, Dag Jacobsen, Bjorn Auestad, Kjetil Sunde: A comparison of intravascular and surface cooling techniques in comatose cardiac arrest survivors .
  • CW Hoedemaekers, M Ezzahti, A Gerritsen, JG van der Hoeven: Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients: a prospective intervention study . In: Crit Care , 2007, 11 (4), S. R91, PMC 2206487 (free full text).

Individual evidence

  1. ↑ German Society for Cardiology. 04/2014.
  2. ↑ bundesaerztekammer.de ( Memento of the original from January 1, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.bundesaerztekammer.de
  3. ^ SE Jacobs, M Berg, R Hunt, WO Tarnow-Mordi, TE Inder, PG. Davis: Cooling for newborns with hypoxic ischaemic encephalopathy . Cochrane Database Syst Rev. 2013 Jan 31; 1: CD003311. doi: 10.1002 / 14651858.CD003311.pub3 .
  4. ^ A b Francis Kim, Graham Nichol, Charles Maynard, A. l. Hallstrom, Peter J. Kudenchuk, Thomas Rea, Michael K. Copass, David Carlbom, Steven Deem, WT Longstreth, Michele Olsufka, Leonard A. Cobb: Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest. In: JAMA. , S., doi: 10.1001 / jama.2013.282173 .
  5. ^ Sue Sendelbach, Mary O. Hearst, Pamela Jo Johnson, Barbara T. Unger, Michael R. Mooney: Effects of variation in temperature management on cerebral performance category scores in patients who received therapeutic hypothermia post cardiac arrest . In: Resuscitation . tape 83 , no. 7 , January 9, 2012, ISSN  1873-1570 , p. 829-834 , doi : 10.1016 / j.resuscitation.2011.12.026 , PMID 22230942 (English).