Zusammenfassung
Fragestellung
Die Praxis der intensivmedizinischen Hypothermietherapie nach Schädel-Hirn-Trauma (SHT) oder Subarachnoidalblutung (SAB) bei Erwachsenen sollte ermittelt werden.
Methodik
Im Januar 2004 wurde der Einsatz der Hypothermie, das Vorgehen bei Kühlung, die Tiefe und Dauer der Hypothermie sowie die Geschwindigkeit der Wiedererwärmung bei den anästhesiologischen Kliniken Deutschlands mit neurochirurgischer Versorgung erfragt.
Ergebnisse
99 (67%) bzw. 95 (64%) der Fragebögen für das SHT bzw. die SAB konnten ausgewertet werden. Hypothermie wurde in 39% nach SHT und 18% nach SAB eingesetzt und sollte in etwa 45% zur Neuroprotektion und in etwa 50% zur Senkung eines erhöhten intrakraniellen Druckes (ICP) dienen. Sie wurde aber in 69% nach SHT und 59% nach SAB bei weniger als einem Viertel aller Patienten verwendet. Ein Kriterium für Hypothermie war in etwa 40% ein schweres SHT bzw. schwere SAB und in 50% ein therapierefraktärer ICP. Die Zieltemperaturen betrugen 36–34°C in 77% nach SHT und 88% nach SAB. Häufigster Temperaturmessort war in über 80% die Harnblase und häufigstes Mittel zur Reduktion der Temperatur in 90% die Oberflächenkühlung. Die Dauer des Kühlens betrug 24–48 h in 62% nach SHT und 29% nach SAB. In 31% nach SHT und 47% nach SAB wurde die Kühldauer an der Höhe des ICP orientiert; länger als 48 h wurde in etwa 25% gekühlt. Nach Beendigung der Kühlung wurde mit 0,5°C/h in 38% nach SHT und 53% nach SAB wiedererwärmt. In etwa 35% wurde das Erwärmen an der Höhe des ICP ausgerichtet und erfolgte in 33% nach SHT und 24% nach SAB über 24 h. Spontan wurde in 24% nach SAB erwärmt.
Schlussfolgerung
Nach SHT wird Hypothermie von 39% der anästhesiologischen Kliniken Deutschlands und nach SAB von 18% in der Intensivmedizin verwendet. Das Vorgehen bei Hypothermie variiert sehr; Kühldauer und Wiedererwärmung erscheinen völlig uneinheitlich. Zum Nutzen der Patienten sollten Evidenz-basierte Empfehlungen zur Hypothermietherapie in deutscher Sprache von den zuständigen Fachgesellschaften publiziert werden.
Abstract
Background
We aimed to explore current practices in use of therapeutic hypothermia after traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH) in intensive care of adults.
Methods
Questionnaires were sent to anaesthesia department chairs in German hospitals with neurosurgical care in January 2004 with a survey focussing on cooling procedures, temperature measurement, depth and duration of hypothermia, and rewarming after therapy.
Results
99 (67%) questionnaires on TBI and 95 (64%) on SAH could be analysed. Hypothermia was used in 39% after TBI and 18% after SAH. Its aims were neuroprotection in approximately 45% and control of refractory intracranial hypertension in approximately 50%. However, in most cases (69% TBI, 59% SAH) hypothermia was used in less than a quarter of patients treated. A criterion for hypothermia was severe disease in approximately 40% and refractory intracranial hypertension in approximately 50%. Temperatures were targeted to 36–34°C in 77% after TBI and 88% after SAH. In more than 80%, bladder temperatures were measured. For induction of hypothermia, surface cooling was applied in approximately 90%. The duration of hypothermia was 24–48 h in 62% after TBI and 29% after SAH. Cooling was orientated at the intracranial pressure (ICP) in 31% after TBI and 47% after SAH, and was used for more than 48 h in approximately 25%. After hypothermia was stopped, a rewarming rate of 0.5°C/h was applied in 38% after TBI and 53% after SAH. In approximately 35%, rewarming was orientated at the ICP, and in 33% after TBI and 24% after SAH, it was performed over 24 h. After SAH, spontaneous rewarming was used in 24%.
Conclusion
Therapeutic hypothermia is used in 39% after TBI and 18% after SAH in the intensive care of German anaesthesia departments. There is no standard in management, and there is wide variation in practices of duration of cooling and rewarming. For patients’ benefit, evidence-based recommendations on therapeutic hypothermia should be published by the appropriate medical societies in the German language.
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Danksagung
Wir bedanken uns bei allen Kliniken für Anästhesiologie, die durch den Einsatz ihrer Zeit für die Beantwortung der Fragen den vorliegenden Überblick ermöglichten.
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Unter der Schirmherrschaft des Wissenschaftlichen Arbeitskreises Neuroanästhesie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI).
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Himmelseher, S., Werner, C. Therapeutische Hypothermie nach Schädel-Hirn-Trauma oder Subarachnoidalblutung. Anaesthesist 53, 1168–1176 (2004). https://doi.org/10.1007/s00101-004-0778-x
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DOI: https://doi.org/10.1007/s00101-004-0778-x
Schlüsselwörter
- Therapeutische Hypothermie
- Prophylaktische Neuroprotektion
- Intrakranielle Hypertension
- Schädel-Hirn-Trauma
- Subarachnoidalblutung