Entwicklungen in der Versorgung reanimierter Patienten seit Implementierung der therapeutischen Hypothermie
Development in care of resuscitated patients with the introduction of the mild therapeutic hypothermia
by Theresa Pelster
Date of Examination:2019-02-12
Date of issue:2019-02-12
Advisor:PD Dr. Claudius Jacobshagen
Referee:Prof. Dr. Anselm Bräuer
Referee:Prof. Dr. Martin Oppermann
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Abstract
English
In two pioneering publications, it was shown in 2002 that the prognosis of resuscitated patients can be improved significantly by treatment with mild therapeutic hypothermia. In 2005, this therapy became part in international guidelines for resuscitation for the first time. The goal of this study was to show the development in care of resuscitated patients with the introduction of the mild therapeutic hypothermia as a form of therapy. In this retrospective study, all the data of resuscitated patients is from patients that were brought to the intensive care unit of the University clinic of Göttingen between 2003 and 2009; data was then collected and analysed. There were a total of 436 patients of which 337 patients also received a mild therapeutic hypothermia. The average age of the patients was 63 years old. Of the total, 66% of the patients suffered an out-of-hospital cardiac arrest. Ventricular fibrillation occurred in 58% of patients when first analyzing heart rhythm. In this case, the patients had a significantly better prognosis than with an asystole or PEA. Reasons for a cardiac arrest include myocardial infarction (44%), major arrhythmic action (23%), pulmonary embolism (5%), and asphyxia/hypoxia (10%). The percentage of the patients who were treated with mild hypothermia was raised from 56% (2003) to greater than 80% (2006-2009). Reaching the target temperature of 32-34°C was significantly accelerated over time: 2003 the time to reach <34°C was 13:59 hours, compared to in 2005 (6:30 hours) and 2009 (2:15 hours). This reduction in time of induction of the cooling correlates significantly with the rate of using cold infusions or the intravascular cooling device (CoolGard(R)). The in-hospital-mortality had an average of 45% and therefore it was below the mortality rate of other studies. Although that patient reached the target temperature of 32-33°C faster than the years before, the survival rate of the group as a whole could not be improved. This demonstrated that the mortality of patients who had an in-hospital-arrest was at 61% in comparison to the mortality of the patients who had an out-of-hospital arrest was at 40.5%. In the ERC-Guidelines from 2015, it is suggested that even the in-hospital reanimated patients should receive the mild hypothermia therapy. Over the years, it showed that more patients came from farther away. In 2003, the percentage of patients who came from outside the city was at 45% while in 2009 the same rate was at 67%. The prognosis of patients who came from farther away was surprisingly better than from patients who lived in the city district. One reason could be that the patients had a longer way to the hospital and already died on the way there. If they had passed away prior to arriving at the hospital, they are not included in the analysis of this study. Overall this analysis gives an overview over the development of medical treatment in the post reanimation period. Because with half of the successfully reanimated patients a myocardial infarction was the reason for a cardiac arrest, a cardiac catheter should be standard protocol after arriving at the hospital. With an early start of cooling the patients and the optimization of the cooling devices, an acceleration of time in the cooling induction can be achieved. Prospective studies are needed to show which temperature management (induction, method, duration, depth of hypothermia) is needed to favor the neurologic prognosis best.
Keywords: mild therapeutic hypothermia; resuscitated patients