Transcript Video First Do No Harm < Back to Summit23 Expansion to Temperature Control First Do No Harm Presented by Dr. Thomas Pellis Yes, thank you very much. So, I it's my pleasure to introduce myself. Um I should be able to do that. Um And now uh after this, uh very, very interesting and provocative uh talk, I'll go with mine, which is uh much, much more simple and down to the ground. So I'll take it easy on you now. So it's very hard to find the way to point. But nevertheless, so my, my presentation is first, do not harm. Uh So we don't wanna harm our patient. Nobody wakes up in the morning to go and work and harm the patient. So, uh our attention and this has been brought up several times during these two days is do not harm. So, in another way, in another way, this title could be seen as to do or not to do rather than to be or not to be. Should we do? Should we take action or should we let it go? Or else we can rephrase this in? Is there a risk to harm with temperature control or is there may be more risk in not doing anything? And this has been bothering us quite a lot. I would say these two days. But what is worrying us when we run temperature control? Let's check on a few items. Is it bleeding? I I think that cardiac arrest patients now, I'm focusing on cardiac arrest in adult patients, cardiac arrest patients are actually undergoing intentional anticoagulation, dual antiplatelet therapy. So I don't think it's really temperature that matters in terms of bleeding in these patients. And we do have data for that. I will take you through the data of the TT M one just because I was uh coordinating the, I was a national coordinator for Italy on the TT M one. So I have a, I, I know quite well depth, the needy and greedy of the of the TT M trial. But as you can see, we checked on a lot of adverse events during the TT M one, we randomized 950 patients. So we have a few numbers there to uh think on and, and, and you can see that bleeding, bleeding, especially in uh dangerous critical sites was a very low and b there was no difference in between 33 and 36 and bleeding from the insertion sites might be an an option or it's something to be worried about, but actually it's very easy to manage. So I, I would leave it aside. Now, uh maybe another issue could be infection. Uh We just heard AAA lesson on that and uh we, if you gather data from all the studies and the patients uh that underwent temperature management, you might be able to find a result on that. But nevertheless, is something that is, I would say uh oo on a lower level of the things that I'm worried about after cardiac arrest, but nevertheless, could be a point. Uh Another issue might be electrolyte or metabolic disorders. Mm. Yes, it could be. And as a matter of fact, during the TT M trial, we found an increased rate of uh hypokalemia in uh patients in the 33 arm. But probably that's because we are not very accurate in what we are doing and we can learn this lesson and be proactive in managing potassium better in this population. Now, let's get to a more interesting topic which is uh arrhythmias. A me arrhythmias has been, have been studied quite well in the TT M one and in particular, we were uh all concentrated on bradycardia. Now, bradycardia is as a matter of fact, something that can happen, but you see that happen uh only in 5 to 6% of our patients, right? Whether they went in 33 or 36 it was not very common. Bradycardia needing pacing. So it's not a big, big deal. It can happen one in 20 of your patients and there is no difference between 33 and 36. And as a matter of fact, um Bradycardia should be also AAA motivator for you because there is literature there that shows says that if your patient is bradycardic, when you manage, you control temperature, especially to a lower level, then that's a hunch of a preserved uh autonomic function of your brain. So it's a marker of a brain that is still reactive. Ok. And arrhythmias, we, we looked for a lot of arrhythmias and, and I would like to point your attention to ventricular tachycardia and ventricular fibrillation. Ok? And you can see there's no difference between 33 and 36. Then the TT M two comes out and we've already heard a lot about this trial. This is the way they manipulated temperature during the TT M two. I was not part of that trial and the results, you're all familiar with the results, there's no difference in the results, but actually, there is a difference which has not been mentioned, pointed out that much, which is in, in terms of arrhythmia, there is an increased rate of arrhythmia in the hypothermia group at 33. And this is surprising when you look at the TT M data. It's, it's a big contrast. So actually you can state that the TT M two is a negative trial although, and this has been picked up by uh Il Corp and uh the uh the societies that publish guidelines, there is an increase in arrhythmia. OK? But when you get into the details of the study, uh unfortunately, there is no uh granular information, there is no that much information as we had in the TT M one here, we have a larger database of patients, but then we we are missing on, on details on what happened in terms of uh what they define arrhythmia with hemodynamic compromise. All that we are given is that in the patients that were taken to 33 °C, um hemodynamic compromise happened in 17 patients and ventricular fibrillation and tachycardia in six patients that then were rewarmed due to this. OK. So rewarming was forced ahead of time in 17 patients due to hemodynamic compromise and in six patients to VFVT. OK. But then look at what a huge difference this translates into in this infographic of the New England Journal of Medicine. OK. And the numbers are very low. At least those we have access to. Mm OK. We can be critic about published data but then we have to find a way to build with it to a better future to make a treasure of it. And uh and keep going, we can't get stick to our usual beliefs. We have to uh improve and that's what we try to do with uh with organizations like Il Cor experts, sit together, they make a task force and then they work on this and, and then this is taken uh that, that Il Corp provides you with consensus on treatment recommendations and then these are translated into guidelines by another uh group of people um which uh uh which uh are part of scientific uh communities. And what does Ilco uh provide, they don't only provide consensus on science with recommendations, but they also give you an idea of why they come up with those recommendations. So this is what they call justification and evidence to decision framework highlights. So what are the, what is the framework? What was the reasoning behind providing coming up with some recommendations? Now, first, I think this is very important as a take home message all all. And this is rare within task forces. Everybody in the task force agreed that we should continue to recommend active temperature control. I think nn no one here that spoke ever said that you should not measure temperature and keep an eye on it and be ready to control it. And there are concerns the task force, the members of the task force recommend this because there are concerns that if you don't do it, you might harm your patient, which is the title of my talk. Um And of course, there is discussion of what fever is right now. I'm surprised this didn't come up that much. But nowadays, we believe fever is something that exceeds 37.3 based on this or 37.7 based on this uh big big trial, big study, observational study on 35,000 patients admitted to hospital with no infection. And you can see that the range whether you want to take a 99% range or 95 leads you to a for example, the 95 to 37 35.7 to 37.3. So that's normal therm. Yeah, that's normothermia for us. What's above becomes fever. And of course, if you stick to this definition of normothermia of 36 you will have noticed. Is it exactly in between? So 36 is normothermia. And if 36 is normothermia and you pull together the data of the TT M one and the TT M two, you end up with unchanged statistical results. So if you feed into a statistician, all those numbers, he tells you that doesn't change much. Another issue I want to point out and we got there during the cardiac session and during the discussion during the cardiac session is that in the TT M two trial, half of the patients enrolled in the normal hermia or fever prevention arm ended up by receiving active temperature management with a device. And you heard from Christian that just left the room going back to his home. Uh That and I was wondering whether to say that out loud or not centers that participated to the TT M two do place the catheter did place the catheter to manage temperature as a feedback control device in advance because they knew half of their patients were gonna become febrile and they would have to act. And as Christine said, you don't want to act at 3 a.m. in the morning or you would, it would take time and you would let the patient be feverish, right? And in the TT M two trial, you should not cross the border this big stop line of 37.8. So it's all a matter of how fast are you in reacting and in preventing what we think can be harmful. So, uh when I was thinking about this talk, I thought, but what is real life? No real life, at least in my, in my unit. Real life is a start to appreciate. You're getting to a dangerous temperature, you're facing a rising temperature, then you have to inform, usually that happens through nurses that inform the physician and probably the physician is busy doing something else. So they have to press on the physician and let's pretend we're all physicians, right? We know that we don't, we're not very reactive to the first announcement of something going wrong. We wanna get more information or confirmation that something is, is, is taking a bad direction and then we have to decide, am I gonna take action now or am I gonna postpone my decision? I'm gonna wait a little bit more. Am I sure? Am I gonna steer up all a huge process for that? Is that enough for me to take action? So again, what shall I do to do or not to do? And then if I decide to act, I have to set up my system and then it will take time to restore normal temperature. So again, uh it's a matter of reaction time. So I don't know how your life is what happens in your daily work. But uh you can either pick the red pill or the blue pill, right? And face reality or keep on dreaming. And in my unit, I have two major issues. One is stuffing nurses. I lack of a good patient to nurse ratio. And then I'm always worried of deviation from what from what we said we were gonna do from our protocol care. These are my two major uh issues. I'm always worried about deviation of from standardized care is ha has actually been uh been uh highlighted several, several times. And you would recognize this slide. I don't need to explain it anymore. I I think 50% of the of the speakers projected this slide because it shows how clearly a change in our mental attitude has taken our action in t in terms of temperature control. But along it, we are afraid a, a change in mental attitude has led to in terms of reduction of mortality that then changes dramatically direction. And that's uh that's provided by the Consortium of Australia and New Zealand. And if you look at the numbers, they're huge. We're talking about 4500 patients. OK? And what they noticed that alongside with this change in mortality, there was an a change in the incidence of fever and they saw a greater incidence of fever which uh as you can see in the last lines, which was not seen in the temperature target uh management trial in the TT M trial. So they say yes, we switched to 36 but we observe an increasing fever that it was not there in the TT M trial. So we are trying to do what the TT M trial is doing, but we're doing it our way. And Fabio has published a, a summary of a huge list of examples of poor implementation, which uh which uh then leads to uh uh a worse outcome. So back to the pills, you can be either proactive or reactive. And I and I urge you to think if you wanna choose for a reactive approach, whether you're really a cutting edge uh center on temperature control or whether simply you don't know how much you adhere to the uh uh to you stick to the um protocol of plane temperature control fever prevention strategy. As, as you heard, many centers prevent fever rather than do temperature control at 36. But then they are extremely ready in reacting whatever you try you decide to do, you should remember why you do it and you do it because of this. Whether it's, it's, it's in Europe or in the US. The main cause of death is neurological injury and neurological failure. That stems from the original itself. Unfortunately, we are left just with the temperature control at this stage as a tool to strive to drive assistance along with it to uh reduce secondary injury or mitigate the effects of that original insult. There were several questions on, on shivering. We discussed about paracetamol, uh which is easy to give and probably has very little harm another, another um way to do it, at least. Uh we, we use it quite a lot is to reduce the effectiveness of the machine of the device we use for temperature control. That's especially after we uh finish the phase in which we keep the patient sedated. And we wanna um and we wanna assess him regularly. So we try to reduce the amount of drugs, avoid sedation and therefore we limit the water temperature. So we are a little bit looser in the effectiveness of the device. We leave uh it's like living at lease that is longer to your dog. We leave more room for fluctuations. We leave the patients uh more comfortable with the, with the water that circulates on them or within them. Another thing that is very important is to keep an eye on the patient. So follow your patient, especially when you before shivering, you can get a hunch that this is coming some hours before because you see that the the trend of the temperature and the modern devices can highlight that they have special features where they show that the trend of the temperature of the patient is rising and you can start looking at the water that circulates within or on the patient that goes down in terms of temperature. So that's a sign that the patient is trying to raise his temperature and that the device is counteracting, keep an eye on that. And then of course, there's drugs we already mentioned uh opioids, but also dex meat toid. Another thing we didn't mention is counter warming, counter warming is basically providing heat on areas of the body that are rich in uh thermal um informations. And that this way sort of confusing your brain, for example, by, by using uh gloves, heated gloves on the hands of the patients or you can use AAA warm air mattress on top of the patient. So that leads to uh confounding information to the brain and paralysis and, and uh and sedation are of course least wanted the last option. And another important message that I would like to give you. Um and I'll skip this one in the interest of time um is that there are assessment scales for shivering. Actually, this has been used in the TT M too. If you Google Shivering assessment scale, you get this slide, that's how I did it. Uh and you just pick the images, OK? And, and, and with this scale comes along and uh a a table that uh can give you a hint of what of what you can use for each and every step in terms of increased shivering. And, uh, with that, I have finished my time and I'll finish also my talk. Created by
