Transcript Video Becoming a Temperaturist < Back to Summit23 Expansion to Temperature Control Becoming a Temperaturist Presented by Professor Fabio Silvio And so I believe that this is the perfect, perfect ending and introducing the perfect end. So with our chair, Fabio Tacon becoming a temper. Yes, thanks. Thanks a lot. Thanks for being there until the end. This is my title and the conflict of interest. Are there any people coming from the UK in the room? Ok. What can you tell me what is the temperature is right? So, thanks Christian for the nice lecture. I asked Cha G BT, I like to use Cha G BT because I didn't know what to tell. You know, I have to say something for 20 minutes. And I said, what's the temperature is this? And she said apologize, but the term is not recognized in the study English in the medical field. So there might be advances because she's uh charge is not updated to uh a a after 2022. So I have now to create these neologism and tell you what the temperature is in a few minutes. So uh of course, is some personal ideas that would like to share with you in the next minutes and maybe five points to remind to everyone. Uh the first thing is understanding the physiology of temperature regulation. And, uh, I, I, no, I like to work on the brain. And, uh, at my home, I always have a book of Neuroscience on my desk because it reminds me how less I know about brain function. Despite that I speak in the medical meetings. And, and so you've seen this many times, there are many tables reminding us how temperature is regulated. And I think you have heard about this, uh this very, quite um uh limited range of temperature when you look at core temperature. And this remind us how important is temperature to our function and how our body react to KSD temperature at that level at which cells work the best. And the hypothalamus, the anterior part of the tham hypothalamus is the most important one. And we need to remind us that we have sensors, the sensors that we call. So thermal receptors are located of course, in the skin you heard, you know, we put gloves when you want to counteract for shivering. And these are basically cold thermo receptors. This is why when you want to shiver, you put the gloves on that part because you want to counteract these cold thermo receptors. And most of the warm thermo receptors are located in the viscera and the spinal cord and in the pi epo theus. This is why it is so complicated with external system to rearm patients that is spontaneously hypothermic. And we have a bunch of um activity and pathways that are activated by our brain and by our body, you see heat loss, uh vasodilation, metabolic rate, uh shivering, of course, that act to bring the temperature back to this level, which is the set up temperature level identified by the hypothalamus. I think understanding physiology is very important because everything we're doing to apply the bed side makes sense if we understand what we do. And if you also think and how temperature is triggered in terms of temperature changes over time, I think of course, everyone knows about bacteria and virus. You have heard about COVID-19 and fever so much time. Uh we think about external pyrogens that trigger directly the dipole or via the vagus nerve triggers, dipole using uh peripheral sensors and these changes in temperature occur. So if you heard, if you take your temperature over the day, there will be changes in temperature over time, which is just physiological and the lowest is in the morning, the highest is in the evening and there is a disruption of this thermoregulation system because we are daily challenged. Even if we are not critically ill to situation where you know the temperature is changing. For example, my room was very high temperature during the night. I have problems to sleep. For example, if you go in the in the airplane, you are challenged with some hypodermic trigger. But in general, our behavior changes and our body can react to easily control and bring the temperature back. So it's important to understand that our body is extremely fine tuning the temperature with a lot of behavior changes to bring it back. And when we have a fever, then of course, can be triggered by these external or internal pyrogens is not only infection is not brain injury, what we have discussed today, it might be also due to other situations which sometimes we under considering the issue like autoimmune diseases, malignancies and drugs. So when you face a problem of fever, of course, you need to understand where it can come from and of course, expand the way of investigation, you might do to understand what's happening. Um When there are disorders of thermo regulation, I think of course we have focused on brain injury because you've heard hypothalamus is injured, the set up of the auto thalamus is changing and of course, the body is differently reacting to the triggers and bringing the temperature up and down. According to the status of the IPO thalamus, I think we are focused on that part of our thinking on how uh temperature is regulated. But you have to consider that there are the situation from which we can learn on disturbances of tempo regulation that happens maybe outside the su and dorine disorders. For example, on diseases, the patients can be apim hyper, you know, hyperthyroidism that is associated with uncontrolled fever. Many patients with a neuropathy, Guillain Barre syndrome present in the IC U face disturbances of the fine tuning of temperature and can experience hypothermia in some situation. I think that learning from these diseases, again, it's a matter of being an expert in temperature because you learn a lot about physiology and our temperature is regulated and honestly, which is even more complex in all the neurotransmission involved in the temperature regulation. We think about the skin. We think about acetylcholine and norepinephrine as the main determinants of azo dilation and vasoconstriction. But there are many others neurotransmission that are involved in that control. And you see from these lights that of course, dopamine serotonin are a system that are much involved into the regulation of the hypothalamus. And we sometimes also forget that if we give drugs because we want to favor temperature control like sedatives or energetics, they can act because for example, there are opioid receptors at the levels of the hypothalamus and central nuclei that are under the control of temperatures. All the drugs that we give in all this protocol to favor hypothermia to counteract shivering. They are basically due to understanding how neurotransmission work and how sedatives energetics interfere with the near this neurotransmission. The second point is developing strategies if you want to be A T, you should implement strategies to temperature regulation. And I think that's something that you have heard a lot of time. The first thing is to have a temperature protocol. I of course, like the concept of a theia and nor theia whatever. But it would be unacceptable that the patients in my department will be treated differently because I'm not present. So it's important you standardize care, you discuss internally, you look at your resources and you try to have a clear pathway on which are the target, how you measure temperature, how long you plan intervention, which are the inclusion exclusion criteria and choose the best methods for the best patients. The other point is patient selection. There is some video that we not discuss enough. And just we make one example, the use of hypothermia after cardiac arrest, I don't know one single intervention in medicine that work in every patient. So saying that I should call all cardiac arrest patients, of course, if wrong and on the other side, there is a biological possibility saying that my work saying that I should cool no cardiac arrest patients is also wrong. Patient selection is something that we should learn from other situations like for example, sepsis and er DS where we're starting to phenotyping patients and they're sending out phenotype of some subgroup of patients within a disease might differently respond to different intervention. This is something to really missing in the field of temperature control, in particular after acute brain injury. And of course, as Thomas pointed out, we should recognize that all the manipulation of temperature required devices require drugs. And when you apply something to the patient, even aspirin, there are potential side effect. So not considering these at the daily basis, whether my therapy is as a balance, a good balance or risk benefit that would be inappropriate in the way that we implement this therapy. The third point is analyzing the evidence and honestly, when you are here on the podium, you've heard different voices with different interpretation of the literature. And uh uh this is something that we should learn from politics. Always beware of extremist, you know, and of course, I will call that's just a joke because I have a picture of people that I'm not saying they're extremist. But if always beware of extremist, basically, you have heard, for example, in cardiac arrest, two different situation. The first one, we have understood that if you are in Austria and Germany, there are no ways to go over 23 degrees, that's clear if you are there and you suffer from c arrest, you will be cool. And of course, this is based on the research these people have done in 2002, which has opened the modern area to manage cardiac arrest. But I think we shall not fail, fall in love with an idea. We should recognize that the understanding and the application of this intervention can change over time. We should embrace the new data coming from the literature. On the other side, I make an example of a good friend of mine, Paul Young, that really is a very great guy, great researcher and this is coming from Twitter now is I he said after TTM two and yet highest quality showed therapeutic does not improve patients outcome, maybe one size does not fit all. And that size is not therapeutic apo that a strong statement from a great researcher that maybe the the exact opposite don't become a trialist just looking at one randomized clinical trial that can respond to all the question in clinical practice. Because not all the patients in a trial will represent the patients you face daily. So maybe in the middle as usual moderate position would be the way to go. And we need to better understand how to apply the evidence. And then we need more research. I lacked the presentation. For example, for Nicole who put together clinical data with experimental data, that's still unnecessary to understand how the biology of a phenomenon can be explained by some manifestation account, therapist can change the response to specific intervention and and aggression. And of course observational trial will not change the practice but are important to build, to build the future, which is of course more randomized clinical trials. So with the idea in the future to better stratify the patients to different possible intervention, identify the subgroup of patients where different strategies for temperature control should be implemented. The four point that's of course practice is you should promote education. If you are interested in temperature control, you should promote education, which is of course, having a continuous learning, read a lot, try to understand behind the guidelines and looking even experimental evidence, all the data that might help you to better understand what you are talking about. Basically temperature control and manipulation of temperature trying to invest in professional development because being a temper or being an expert in the field also is a professional development possibility in the future to be involved in in the group of people working on some ideas developing. For example, new trials, be advisor for companies, old experience will tell you something will make you learn how to progress in your life and of course participate to meeting, think I have nothing, there's nothing to hide. I mean, I like the approach of BD because for 10 years, they promoted the meeting on TT M where all the people with different ideas on temperature control were invited. So it's not it's more based on education than promoting a device. And of course, we need this kind of meeting to share experience and to help people experience interpretation of the literature too uh progress. And maybe in the future, even certificate like echocardiography or like a certificate in sepsis management, maybe also temperature control which expands beyond cardiac arrest and trauma might be sepsis. Maybe maybe in the future, maybe certification on how we apply temperature management in the in the in the clinical feed would be the issue. And the last point is, of course, if you become an expert, don't forget to transmit what you have learned to the others and to promote knowledge. Of course, don't forget that if you, if you want to be an expert of patients without seeing patients that doesn't work, you know, I try to do half of my time in clinical practice because we are IC U physician, IC U nurses, IC US health care providers. You cannot tell the others how to treat patients if you don't see patients. So clinical practice tell you a lot to understand how the results of the clinical trials can be applied at the bad side. Second use simulation, use a setting where you can recreate what's happening in trials and try to understand how to improve the quality of care in particular of temperature control, you're giving to the patients, creating network network of people that have different opinion than yours that might help to share knowledge and maybe create the future protocols to be implemented. And of course, if you become an expert in the field, don't forget to mentor the others. There are people who come to you, to ask to have ideas on research is our role. Your role. If you become a temper to mentor these people to drive them through the good ideas in research could be experimental and clinical and maybe in the future be part of a large group of people. And then of course read again because we are discussing about devices. We are discussing at manipulating something that our body doesn't want to have. But there are drugs that are in development that might manipulate the neurotransmission. These are only some of them, they some of us will prefer cannabinoids for different reasons. But that's another story. These drugs can potentially manipulate the way that the body react and controlling temperature in the future might be a combination of drugs and devices for an even more accurate control of temperature. So I conclude with this, I like JG BT. I asked JG BT to write a sonnet in English to uh on temperature control. I will read it with you. It's not very easy for me to read. But you will see in su where lives imbalance, softly swayed temperature, art in healing holds it might in fevers fire or chilling cold. We stay to guide its fragile breath to darkest night with fever blaze, we quench the flames that rise to cool the fever, bro. A soothing race in a poder grip. We warm the skies to keep the vital spark in its rightful place in every bit in every labor breath. Temperature dances a lifeline to the soul in iu embrace, we conquer death to mend and make one's broken spirits whole to cherish temperature, vigilant. Art in is u realm immense the human heart. I don't understand what he's saying, but it looks nice. That's why I present it to you. So thanks a lot for your attention. Created by
