Transcript Video Cracks in the Ice: Panel Discussion < Back to Summit23 Cracks in the Ice Panel Discussion Presented by Associate Professor Katia Donadello, Professor Raimund Helbok and Professor Bernd Böttiger Moderated by Professor Fabio Silvio Taccone Can we can stay on the on the scene? Be with Kia and Raymond. Please take a seat and we have maybe a 20 minutes questions before the break. So we have of course heard about many things about how and why we should measure temperature is fever be historical view on how we move from a terminal temperature control. And a more uh I would say strong statement about how to manage temperature again, very much focusing on cardiac arrest. So I have uh this in my hands because people can also join through virtual and maybe I have a question, I can read it if you will also use the application, send the questions. I can also read them for you. Who wants to start? Who wants to start? Who wants to start? Yes, please. Maybe if we have a microphone. Yes, we have a question there. Thank you for the marvelous presentations. Really eye opening. I wanna hear more about the Princess trial and why it was stopped early because a lot of us really believe in early cooling and this was quite a disappointment when it came out negative. And so maybe doctor Taone can tell us a little bit more about it. Yeah. Uh I think we, we will hear about Per Norberg who is uh the P I of the study with friend also. So we have been working on this project seven years uh rapidly. We we were, we had planned maybe not 3000 but more than 850 patients. With the idea that the calculation was made on the proportion of patients admitted to the hospital. This was the signal and this is how the patient, the paper has been submitted. So we we reached the 300 something patients admitted to the hospital. But clearly, this was not enough to provide enough statistical power. Again, this came from a phase two when we probably underpowered the intervention. What is true is that if you want to provide an effectiveness, taking all the C patients being treated unseen during CPR, you would require more than 2000 patients. And after seven years of hard work, only 670 patients being included would have been impossible to do more. So now we have the princess to trial, which is the ongoing idea. We discuss this tomorrow on the concept of early cooling. Any other question? If not, I can maybe maybe start from Katia. Uh So you made the point, how do you think that people should implement the temperature measurement? Because I think this is really the starting point, whatever you would do hypothermia oria, I think we still stick in the survey. As you mentioned, we don't know exactly what it is continuous. If it is continuous, where do we measure, which are the site, what you really discourage to use, which are the best. So first of all, I believe that we have a problem in the uh day by day attitude. And I realize it uh in my day by day practice within the team I work with um because it is not that obvious to put a probe and to measure the temperature continuously. And if it is done, what is prob the main problem that we face is the fact that often temperature alarm is silent. So there are no borders and there is no voice of the actor. So um as I said in the picture first, I believe that it is necessary to have this idea in mind that in critically ill patients, temperature should be considered as it is as a vital sign. And so it should be monitored continuously as the other vital signs. So put on the monitor with the same power and the same presence as the others. It is not necessary to have a trace, but at least the number and we need to have an alarm because for instance, if your patient, I mean, I believe that most of us uh have uh 2 to 1 nurse to patient ratio, uh patient to nurse ratio, sorry. Um and usually, I mean, in my IC U nurses uh uh do it around with patients. Uh once every two hours they start and they finish and then they restart. So if I consider patient one and uh we just monitor the temperature punctually, the problem is that uh going to the second or third or to the, the evaluation thereafter, temperature might have changed. And if I monitor it continuously, but without an alarm, the time the nurse get there to monitor it again, temperature might be 38. And the time that we start doing something and that this something gives us a result, my patient's brain temperature might stay at 38 for more than one hour. So if we believe that uh hyperthermia fever might be as Ryman said, deleterious without knowing precisely in which detail it is because our reaction, even if straightforward might not be able to give us a result, straightforward. I think Raymond mentioned very briefly in your presentation that the difference between brain and core temperature. So I don't know how many people in the room routinely measure brain temperature just with your hands. Only very few of us that have the possibility, which is to you, the closest side. I mean, which is the other side that is the closer in terms of temperature to the brain, the one that you would advise. Ok, you don't have the brain temperature, but please measure that side because that would the closest one to the brain that's a, that's a quite important question where to measure temperature. And that was actually the content of the talk uh previously. But uh so we, we have to have a core site and there are pros and cons for measurements in different sites. Esophageal temperature, for example, is one that comes very close. The bladder temperature is, is mostly used, I would say in clinical practice, we have a delay, a certain delay in the measurement and the actual temperature, the core temperature. And that's a problem. But that's actually the best we have. And I think we should, we should measure it continuously is much more important than precisely where. But if we have the optimal method, it would be the central core measurement in the esophagus but mostly use the bladder measurement and brain temperature. The question is always should we then react on brain temperature. And I think that's thing is totally open for discussion now. But if I think that I would want to provide the best treatment for certain patients, then I would even include brain temperature. But that's an individualized approach in a certain setting. Can you briefly remind everyone why skin and rectal temperature is not adequate for those who are still using it because auxiliary temperature because they are out of range. And we know that there is a huge variability and they are affected by so many other other external causes in the ICU. And that's why. So first continuous measurement and central measurement. I think that that's the big points to discuss here before going to Bern I see if there are questions from the audience because it's important for you. Yeah, please. Hello. Uh Sorry. Um I would go a step further. Second one, someone else with a microphone, right? Yes, sorry. But please speak. Can I speak? Uh I think temperature curve is just like the IP curve and IC P is more than a number. So I think that maybe in the era of individualized precision medicine, we should have continuous uh high resolution, high sibling frequency value from temperature, analyze the patterns, the different patterns of complexity of this curve and try to find out different pathways. You mean how a patient is going from one state dynamic state towards another? And also another suggestion we know from young buggers work from uh Netherlands that we can measure at the same time, different points of temperature that can assess indirectly microcirculation hemic status. I know what you have to comment on this. Thank you. Absolutely. So, but uh even I I would like to answer this way. Even in the brain, we have different temperatures in different areas because the brain is I is in different active stages in in metabolism uh near the injury and then may maybe in the peral area and in the healthy brain. And that's also something we can discuss. We put a probe in. How do we measure brain temperature by any imaging methods that's not ready. Now, we have temperature probes, we measure it locally and that's why should we actually target the brain temperature in these patients by local measurements. We can say yes or no. There are pros and cons about it and that's much more sophisticated. But it comes to the point that local perfusion is very important for regular and also a certain high resolution. We will not come to the curve in that high resolution. But we have these, I would say every five minutes for information for the temperature is enough to see these variations because it's not that rapid as ICP changes. But yes, we need, we need a continuous measurement to integrate it in daily practice. And uh if we, if we provide treatment like pharmacological treatment, we will, we will actually put the patient into these variability in temperature curves. And I'm pretty sure that this is not good for the patient. And that's why if we, if we define that a certain target is actually the way where we want to go, then use a feedback device and use it properly and go to the target. And I think that's, that's a very important point. And if you see the, the TT M two trial or the TT M trial, and you see the huge confidence in the, well, you see that patients, even though they were, they were in either the intervention group or in the control group there were some patients who were totally overlap and even though they were dedicated to different group, they had the same temperature curves and that's why I think that's, that's very important going continuous measurement, but not that high resolution. I'm not, I'm not seeing the value of that. I can see Nicola Day from here. Now, a question, please. Nicola. Hello. Uh Thank you so much for your slides and presentation. Uh Very interesting comment about the nurses in our IC U. We have only one nurses for three patients. So imagine how I am afraid in post cardiac arrest patient. If I don't use device or if I don't set the alarms. Thank you for your comment. But I have one question, sorry for burnt and uh fabio uh how to move forward and to correctly select patient. We have biomarkers. I know it's not very uh useful or it's not very published at the beginning to select the patient with the accessible uh uh brain damages. We have maybe biomarkers and maybe eeg we, we have to select probably patient according to new guidelines and I want to, to have your uh uh answers. Thank you so much. Which is your idea? You mean selecting patients for temperature management? Ok. I think I don't have anything in my mind that will give you within 30 minutes, any information, whether in this patient, it is useful and in that patient, it's not useful. And as Peter Saar said, you need to start within 30 minutes and maybe earlier and nothing will help you then not an eeg not neuron specific analyse not S 100. So nothing will help. And, but, but the good thing with temperature management is with hypothermia that has also been shown in the TT M one and TT M two trial for this. These trials have been good because the good thing is there are no side effects or at least no prolonging side effects that affect overall outcome. You can find a little bit higher rate of hypokalemia, a little bit higher rate of arrhythmias. But that you can correct in an IC because that's the, that is where the IC is for. So I would like to repeat what a cancer patient would say if you, if you tell him there is a therapy, we don't know whether it's useful in your, in your, in your case. But in some sub groups, it is useful but it does not have long lasting side effects. And I would promise each, each cancer patient would say please give it to me. And that's how we doing in cologne. If a patient is telling us after cardio gras, please don't do it because it's too cold for me, then we would not cool him down. But all the other patients get cooling in my department. I would say that my side, we have published a study on admission pupil data. 3% false positive rate. So if you have bad pupils, 3% chances you will recover properly. And if you put an e very early and looks normal, there is no sense to put hypothermia. These are to me, but this should be studied. I mean, that's my opinion. We are running, we will run now in France, Belgium and a few other countries. And another study for in hospital, cardiac arrest and hypothermia. And in some centers, we will look at pupils and eg on a mission to say that whether, whether we can identify patients, you know, that are too sick or too healthy to be treated. So that's the future for next trials. I think are there any other questions for our panel? We still have five minutes before the break. I have a question for the three of them. But so the question I treat them starting from burn to cardia to Raymond. We talked aloud a little bit about how to measure burn alluded to hypothermia. Now, my question is, how would you define fever in your clinical practice? Because Raymond said if you ask other people, they will have different threshold which is to you in a setting of course, of acute brain injury to be more precise, which will be to you the trigger or the identification of fever in these patients. How would you, I mean we discussed that a lot during the guidelines development and the recommendations in Ilco and in the European resuscitation council and it is anywhere between 70 37.5 and 37.8 °C. And the latter one is the, the border that we are using in our recommendations. Thank you. The alarm on the monitor is set at 37.5. In order to be able to act, I think we have to define normal fermion and then say, well, uh everything, what is not normal fermion is, is either below or above. But I think normal theia in the range is between 36.5 and 37 per cent. But we also know that there is a variation during the night and during the day. And so we don't, we don't integrate the circa rhythm now in our thoughts. But I think no theia is somewhere in between these ranges and that actually comes to the same that above 37.5 I think we should, we should treat fever um especially in these patient population. But if I have a patient who is severely sick, and I would, I would want the best medical treatment, then I even don't want a single episode of fever to happen because I know that with the pharmacological treatment of 37.5 I'm not very effective in decreasing the temperature to 37 degrees or even below. And that's why especially in these patient population, I think we can, although we don't have scientific data for that be very active and aggressive in prophylactic treatment. And how long would you treat fever in crest patients? So, um in, in general, in acute Liberian patient, it totally differs from the disease and also also from the patient. But uh uh longer, uh not, not for 24 hours only. I would actually recommend to treat longer, longer means we know there are some data between three and five days. But we have to say we have to say that not every patient benefits from that. And it comes to the very good question. How do we identify these patients? Can we maybe identify these patients after 24 hours or after 48 hours? And to say, well, this is a patient where prolonged hypothermia and maybe that's a way to go and this is something we should discuss. So a few questions now from the online system, there are many. So we try to make one question for each of you, maybe short question, short response starting from Kia. What about the fact of cooling on patients who have risk of bleeding? We use it. Is it forbidden? We try to use it. And if it is not manageable, we reduce the rate of cooling but it is not an absolute contraindication. So there is no need to avoid that. And Bruno Levy, I'm sure will talk about that rafter uh people on ECMO are prone to bleed but they are not excluded from temperature control because they are at risk of cool of bleeding. Now, a question from bird, that's specific. So when do you think TTM is not useful in cardiac arrest? And can you stratify patients according to rhythm bystander encephalopathy to treat with hypothermia? I think you partially answered the question. But it's again pointed out in the Q and A, we would only avoid TTM in patients where we have clear evidence that they don't have any brain damage. That means in a patient that is awake or in a patient where I'm sure that she or he has no brain damage because CPR was started immediately. But in doubt, we're cooling because we are then on the safe side because we don't have long lasting severe side effect. So there is no harm with it. Um Except the fact that you probably prolong IC stay for one day or so. Uh I think uh still another question from Raymond. So they, they are talking about IC U patients admitted with hypothermia. So already with severe hypothermia, um should we still consider TT M in these patients? So control, of course, the warming, should we keep them hypothermic or bring it to normothermia? Of course, you can discuss about, you know, cardiac arrest patients when general patients found hypothermic without arrest. So I think it's, it's nicely shown in the case report that rewarming to a certain degree makes sense, but then do not rewarm the patients because because uh they, they will anyway get warmer over the time. And I think rewarming is something we shouldn't, we should discuss and we never discussed here. We should be very cautious about that going back to normal temperature but actively rewarming in cardiac arrest patients where I target normal theia. No, uh wait, wait, wait for the patient to get to, to. No, no, in high severe hypothermia. Obviously you have to, to reform the patients actively. I, I would like to add, I remember a double case report from Berlin in Germany. Some years ago, we twins, I don't remember the age, maybe eight or 10 years old were playing on, on an ice, on ice, on the sea, on a lake and they both went under water and were rescued more or less at the same time. And they were transported in different hospitals. In one hospital, the one twin received rewarming until normal, up up to normal theia and in the other hospital, the other twin received um rearming until 33 °C for at least 24 or maybe 48 hours. And the latter survived in good conditions. And the previous one who was rewarmed until until no theia had remarkable brain damage. That is just a case report or double case report, but that is leading our therapeutic approach in such cases. I think the discussion we had the focusing in on arrest. We nicely prepare the second part of the day where we will discuss about new needs and then we have a very nice procon debate on a tur and card arrest. So I would like to thank the panel for the discussion. Thank you, everyone for the first part of the day. People on virtual. It is now time for the break. Created by
