Transcript Video From Guidelines Via Cochrane to Individualised Patient Care < Back to Summit23 Cracks in the Ice From Guidelines Via Cochrane to Individualised Patient Care Presented by Professor Bernd Böttiger Now we introduce the last speaker before the panel discussion. Professor Ben Botting a very well known expert in the cardiac arrest field involved in the guidelines in implementation of Knowledge, University of Cologne in Germany. The title of the lecture is going from the guidelines to individualized care, Berner frauds. And this is the pointer, please. Thank you very much, Fabio. And um thanks to the organizers to invite me to this wonderful symposium. I'm very happy that you are all here and thanks to the previous speakers, gave me 10 minutes more for my talk, isn't it? We, we, we, I I would allow me to be a little bit more interactive if you agree on this, but I will promise it will not take much more than 20 minutes. So, um this is the title of my talk and I need your help with this guy who is this most Christian Erickson. So who has seen this in television when he collapsed during the soccer game about two years ago, uh Please raise your hands. So many have seen it. So if the heart is not pumping blood anymore to the brain, people get um unconscious within 5 to 10 seconds. Did this guy need hypothermia or temperature management? No, why not? He was already on Instagram again in the afternoon. This is the picture from the afternoon after his categories because he was resuscitated immediately. But the good thing with this is he's playing against soccer. So he survived in good conditions. And the good thing with this is he supported our initiative. We have approached the UEFA and we will have a big campaign on resuscitation coming with the UE Uefa European Championship in Germany next year. So you will hear a lot more from cardio rest and cardiopulmonary resuscitation here. You can see my oops that was very fast, my potential conflicts of interest. So what is most important, most important is not cooling or not cooling, epinephrine or norepinephrine. What is the most important? This is most important and you need to do it hard and fast. And then all patients would be able on almost all patients if they are on social media to be on Instagram again in the afternoon. And that's our goal. As you can see here, you have the collapse and the professional ems is arriving in my country after 7 to 9 minutes. But this unfortunately is too late because the brain can only survive for 3 to 5 minutes. So there is a time window for lay resuscitation. We know from the literature that like with Christian Erickson, it was not laypeople, but laypeople can do the same as has been done with Christian Erickson. There is a time window for lay resuscitation. And if lay people start with resuscitation, survival rate is three times higher. And you probably have seen the chain of survival and this is the new chain of survival. And as you can see here, this is based on real data. You can see that early recognition and call for help. This is the first chain is, is the most important. One, early CPR is the second most important one. Think about Christian Erickson, early defibrillation is not as important and post resuscitation care. That's our topic today is also not so important. That's probably the reason why we have so many conflicting studies in this area. And I would like to show you a national initiative from Denmark who is in this room from Denmark. So you are from Denmark. So congratulations to that study, national initiative with the help of her Royal Highness and many others in Denmark. 10 years, 2001 to 2010, they started with a bystander CPR rate on the very on the left side at the bottom. Bystander CPR rate of 20%. And they raised it in the meantime to 70% or something like this. And in this 10 years period, it came close to 50% and they did a lot of different things. One thing they did was mandatory education and resuscitation in all elementary schools that is needed why isn't it? The law all over Europe? They are discussing now reducing the rate of traffic death accidents. But this is only a limited number of people in Europe. We have 350,000 deaths by cardiac arrest every year. So the EMS is going to the patient but the patient does not survive because the EMS is coming too late. This is 1000 deaths per day in Europe. This is uh as if two Jumbo jets would crash down without any survivors. And the Danish people made a big good study an example and they introduced school Children, education in CPR. Can I ask you where is in your country? School Children, education and CPR mandatory? Please raise your hand. I do not see so many hands. So this increased bystander CPR rate. And what does that do with the outcome? The outcome within 10 years in a deadly entity was increased by three times. So we have many doctors, nurses, paramedics in this room. Can you give me another example? We're in a deadly entity. The outcome, the survival rate was increased by three times in 10 years with any drug, any other intervention regardless about the costs. Can you tell me something? Does anyone know anything? The only thing you need here is two hands. Why isn't it mandatory to educate school Children in CPR? So if we would have the same development as in Denmark and Germany, we would speak about 10,000 additional lives per year in Germany. This is four times more than we have with traffic accidents. It would be more than 300,000 lives in addition, surviving in the world. So the only thing people should know is check, call compressed, check for signs of life called the Ems and compress because there is no oxygen anymore because the brain is using so much oxygen. But in all the other parts of the body, we still have enough oxygen. So I'm coming to the er C European resuscitation guidelines from 2021. It's the most recent guidelines. You probably know them. We have very nice infographics here. Priority number one. not too much and not too less oxygen. Priority number two PC I at least in ST segment elevation infarction. Prior number three was temperature management. These are the recommendations from the guidelines based on TT M 1, 32 to 36 degrees for 24 hours and avoid fever for another 72 hours. Prognostication, not within the first three days. Otherwise people that have the chance to survive will probably not survive because you um stop therapy too early and rehabilitation is also another issue. We have very nice infographics in our guidelines. So please have a look at it at it. It is very interesting categorized patients should not go just to the next hospital. At least if they have ST segment elevation infection, they benefit from being transferred to a card rest center where you have PC I facilities a valuable 24 hours a day and seven days a week. As you can see in this meta analysis and many studies are supporting this, there is an increase in survival if you go, if you don't go to the next hospital, but to a cardio center doubling in survival with cig rest centers. This is our German logo for C centers together with the German Society of Cardiology. The German Resuscitation Council has already certified more than 100 C centers all over the Germany and also in Austria and in Switzerland. And we also now have requests from Belgium. So implementation in Germany, not bad in Europe. We are in discussion with the European Society of Cardiology and there is some progress also in Europe. And now I'm coming to temperature management and hypothermia and I would like to invite you to the winter in cologne and yesterday it was heavily snowing in cologne. So the winter is coming back. And some years ago, we had an alarm child under ice and water. Six years old firefighters were on the scene. So the child was playing together with his friends on ice and then the ice was broken and he was under ice in the water. Water rescue started five minutes later, time in icy water at least 25 and maybe 35 minutes, they put the boy out of the water. They started cardio compressions and cardiopulmonary resuscitation. And they brought him to our, to my department during ongoing CPR. He arrived after being in the water of at least 30 minutes and after having um CPR for more than 1.5 hours, he arrived in my department with a Glasgow coma scale of three with white pupils with apnea with the temperature of 23 °C. And with aces to, we did another CPR for another 1.5 hours and then we put him on egg more, but we didn't increase the temperature to normal therm. But we increased the temperature to targeted temperature management, 34 °C for 72 hours. Then we weaned him from ECMO. Two days later, we let him wake up and we extubated the trachea, the parents were with us in the room and we were all very interest. It, it was a very emotional moment. What would happen to that guy and he opened his eyes and he said, can I have a nutella bread? That was a very touching moment. And you can imagine how we felt after this. I mean, some colleagues, one colleague in one of the sessions I showed that said that if he is asking for nutella bread, then he must have some brain damage. So early hypothermia is effective. There's no doubt about that. And why is that? Because this is, this is the most important word here is simplified, this is a simplified model of mechanisms following ischemia. You have seen similar graphs from previous speakers, simplified, simplified. So you can block one pathway and you have a nice publication but it does not work in humans. But the good thing is hypothermia is is influencing all the pathways you can see here in a positive way. And that's probably the reason why we have also in the clinical setting, positive signals about hypothermia. And you have heard already from that study from France, from Las Caro and others targeted temperature management for categorized in non shock rhythms. And as you can see here, hypothermia was associated with a significant increase in survival and good neurological outcome. C PC scores one or 21 day 90 doubling in good outcome significant. You also have heard about the Princess trial. The princess trial means that you have nasal cooling with perf Carbone. So the brain is initially cooled very effectively. You can also put these cannulas in at the start of CPR during ongoing CPR. So cooling started with start of CPR. Unfortunately, they enrolled only 677 patients. They were aiming to enroll 3000 patients but it took it took too long. So they stopped the trial early. But subgroup analysis in this trial showed very nice results, complete neurological recovery with cerebral performance category one and two in patients with ventricular fibrillation significantly higher with the intervention as compared to controls and time to cooling was important. We have heard from Peter Saar that he already suggested in the early sixties, Fabio told showed us that slide, that cooling should start within 30 minutes. This is probably very similar to what they have found in the clinical setting. So if you start cooling within 13 minutes or 19 minutes, it is much more effective as compared to starting cooling, cooling later and I will come back to this. So we are always cooling our patients for at least 24 hours and maybe longer. And we are cooling as soon as possible and not after 238 hours. But as early as possible, how long you have also heard about this trial? Probably they compared cooling for um 24 to 48 hours. There was a slight signal, it was not significant that cooling for a longer period is more effective. They found 7% more survivors, but this was not statistically significant. So coming back to the year 2021 I repeat what we have what we have recommended to the world, not only in Europe temperature management, as you can see here, 32 to 36 °C for 24 hours, avoid fever. And then, and then TT M two came out, it published in the New England Journal. And um it is worth to read the whole paper very carefully because as you can see here, they because of the patient selection and because of the selection of countries where this study was performed. They had a bystander witness categories of nearly 100% bystander performed. Cpr 80%. Can you please raise your hands if in your country? Bystander CPR rate is 80% Denmark. That's it. And the first cable rhythm ventricular fibrillation, more than 70% in my country. 20%. Can you please raise your hand if in your patient population? VF as the first rhythm detected by the EMS is 70% not even in Denmark. OK. So the these these patients are not my patients and maybe also not your patients and then look at the temperature curve. So ours, you can see the temperature was reached after six or seven hours, but this was not seven hours after cutting rest, this was seven hours since randomization and it took more than two hours in this study to randomize the patients. So this is more than seven hours after the arrest, they reached the targeted temperature. Please remember what Peter Saar said in the early sixties start after 30 minutes latest. And that is the reason in my eyes why they didn't find any difference. That is one of the reasons between the two groups and a very high survival rate because maybe there were many um people in that they didn't need any kind of temperature management. So many Christian Erickson is probably in this trial in this setting, I would hypothesize that even fever would not be harmful, which is a little bit a provocative statement. But unfortunately, in the TT M trial, the ischemia duration before CPR start was not reported for any reasons. But in the TTM one trial, which was probably the same study population ischemia duration before CPR start was reported in the table in both groups less than in median one minute in median one minute because they had such high rates of bystander CPR. And if you have one minute downtime, please rethink about Christian Erickson. You probably do not need temperature management or cooling because there is no damage to the brain. And as you have seen, the target temperature was reached more than seven hours after c rest which is much too late lac pr rate more than 80% in Denmark. This is reality but not in the rest of the world shock of a rhythm, more than 70%. It's not our patience. So in animal studies, maybe you can help me. We have a lot of animal studies showing that TTM is highly effective after global ischemia and cats. But does anyone in the room knows one single animal study? And we have thousands that are positive. Does anyone in the room knows one single study in animals where reaching the targeted temperature after more than seven hours after card rests has a positive effect. Please help me. I don't see any hands raised. So, are these patients our patients? I'm telling my colleagues when the patients in my department are the same as in TT M one or TT M two, then please follow their recommendations. But until then, please let us do it as we did it in the past before TT M one and TT M two. You have already seen by Fabio Taona, the er CE S IC M guidelines that were then changed after publication of this study, what you can see is that we only have lower moderate evidence and in most the most recommendations are just good practice statements. And I was fighting very much in this group for the statement that you can see here, there's currently insufficient evidence to recommend four organs, temperature control at 32 to 36 degrees in subpopulations of categorized patients. And maybe the population in my country is a subpopulation and maybe also in your country because you don't have these high lay resuscitation rates or using early cooling and future research may help elucidate this. We recommend not actively rearming. OK. That is clear. So think about animal studies. And then after the publication of TTM two, we did an analysis and we have looked at all published studies on the use of TT M following card or large scale studies. And you can see here on the bottom, this is the bystander CPR rate and if the bystander CPR rate is above 70 or 80 which is only the case in Denmark, then you can see the absolute benefit per 1000 patients treated for hypothermia. There is no benefit anymore, which is clear to me because they don't have a damage or a major damage. But if the bystander CPR rate is lower than let's say 60 then you have an increasing effectiveness of temperature management. So these are our patients in green and this is also applying to Christian Erickson who received immediate bystander CPR. You have already seen from FABIO that the effects of target temperature management on comatose patients after cards can probably be stratified by the severity of encephalopathy. So if you have, if you have a Christian Erickson, which has been resuscitated immediately there, that does not make a difference whether you call him or not. If you have an intermediate damage, then cooling is effective. And if you have a very severe damage patient with asystole without any bystander Cpr unwitnessed arrest, it does also not make a difference whether you cool this patient. So as you can see here, mild encephalopathy, this is our Christian Erickson. No use. But if you have moderate encephalopathy, then you should cool. And then the question is how can we, how can we know at the beginning of treatment, whether it is moderate or mild or severe? And I was at the meeting some days ago and to a colleague asked the question to the public. So please think if you would, if you would speak to a cancer patient and you would have a therapy that is effective, but only in a subgroup, even if the subgroup is probably the majority. And you tell him, we don't know whether it is effective in your case, but it's effective in the subgroup. But what I can also tell you, it does not have any side effects. What would the cancer patient say? That's the reason why we take 32 to 34 °C for at least 24 hours as soon as possible. And you will hear hear Willy Beringer very soon. So he will also give us his meta analysis, the real meta analysis, not excluding some studies were. What other meta analysis did? You will hear a lot from him about this later and my last slides Cochrane library published in July hypothermia for neuro protection adults after cut grass. Please raise your hands if you have seen this. Ok. Thank you very much. So, not everyone, neurological outcome significantly improved with hypothermia at a level of 32 to 34 °C location of card. Does it make any difference between in hospital or out of hospital? Card? Rest in both groups. Hypothermia is effective and this was very nice to see because it's more or less the same analysis that I have shown you from my department. Bystander cardio pulmonary resuscitation rate more than 70% no effect because there is no damage. Um Bystander cpr rate 43 to 59%. Who in is it where, where is it? Please raise your hands. If your patients are in this range. You OK, there is a significant effect and then bystander CPR rate less than 42% whose patients are in this range. It's probably most of the patients there is again a significant effect. So that's the reason why we are cooling for at least 24 hours. You probably will hear that trials on early cooling, real early cooling. Remember Peter Saar start within 30 minutes are on their way and we have just accepted, they have just accepted the publication where we have done this analysis, analysis and cooling for all our patients. And my clear message is this and don't forget nutella. Thank you very much. Created by
