Transcript Video Guidelines Vs. Reality < Back to Summit23 Brain Injury Management Guidelines Vs. Reality Presented by Professor Bruno Levy So back to work. Um It's my pleasure now to start this uh focus session on cardiac arrest and uh to introduce our first speaker, Bruno Levy. Bruno Levy is uh the head of the Cardio Medical and surgical Division. Please step up of uh and head of the intensive uh medicine resuscitation department at Nancy Barboa. He's most of all, he's a active uh researcher in the field of hypothermia and he's api is api of an interesting study, but we'll hear about that later during uh at the end of the morning. So, Bruno, please. Thank you very much for this uh very nice uh introduction. So, good morning, ladies and gentlemen. My name is uh Bruno Levi and I work in the east of France in uh Nancy. And uh during the next 1520 minutes, I will uh present you a survey that we perform on front on post Kia car care in IC U. Of course. And uh my presentation will be mainly focused on TT M. So first, uh uh the methods we uh perform uh two Declarative Web surveys uh from March uh 23 to uh August uh 23. Uh this survey were, the question of the survey were based on the most current uh recommendations. Uh One survey is for the physician and one survey for the nurses. And uh we work with 389 departments and this represent 276 French IC U. And we also perform a comparison with uh the survey of uh Nicola Day, which is presented in the room. And the survey was uh published uh I uh 2015 after the TT one, TT M one study and uh the French Society of uh intensive care provide us uh uh individual patients data to perform the comparison. So, you know, we use three recommendation that are similar, the, the UK and the USA recommendations, you know very well. Now, I think the story that was described yesterday first, the seminal study which found a very impressive difference in favor of therapeutic hypothermia. And this uh study was uh followed by a lot of uh so called negative studies. The first one, the TT M one, no differences between uh 33 and 36 group. And this uh led to a change in the management of uh patient after cardiac arrest. And uh this slide was uh also shown yesterday and the temperature progressively increased from 33 to 36 both in the USA and in Australia and New Zealand. After that Nicola Day published one survey after TT M one and we will discuss the results and we will compare the results of that survey when compared to the 23 surveys. The next slide. And finally two negative studies, one positive, one negative. The first one by car from French, which found by moderate hypothermia might be beneficial in patients with non checkable rhythm and the last one last year. So don't give it and one more, no differences between nomo tia and hypothermia. So, the results of the present survey, first, you can see on the map that we work with a majority of center that are similarly equally distributed in France, mainly in the north of France. Maybe something that has to do with hypothermia. Uh The main uh pay uh main characteristic of the respondents. Uh First, uh uh it's public uh hospital mainly in uh more than uh 90%. Uh uh our respondents work in a public uh hospital. Uh I've no point and I'm sorry, but uh you can see uh he has a distribution of the number of, of uh patient for cardiac Rights in the IC U. And you can uh uh observe that uh approximately 40% of uh the IC U uh receive less than 30 patients for cardiac rights per year. And uh approximately 25% of the units uh treat more than 50% per year. So small center, big center uh over characteristic. Uh So they use uh uh recommended, the recommendation published by V AC or RV. Uh And uh some uh approximately half the units have mo on it but uh generates a public university hospital. And uh the very good news uh and it's not new but I France in 23 uh majority, big majority of the units use TT M. This slide uh present the evolution uh in the target temperature. Uh First uh uh yeah, you can see that there is a very huge difference between uh uh 3015 and 23 in brown and uh uh in uh yellow and the temperature um back the increase. And uh in uh uh the last year uh in tw in uh 15, uh uh they use uh uh hypothermia in approximately 62% of the patients. And in 23 you can observe a very, very important decrease, approximately 15% of the page of the u the centres use a moderate hypothermia tia. And you can see that the majority of the French now use normal Taia. And it is also interesting to note and you can observe here if we, when we separate the temperature by degree, you can observe that approximately 20% of the center use uh 45 degrees which is between therapeutic hypothermia and normal tia. So uh some difficulty to choose the target temperature and you know, very well this uh this slide. And if you have a look a t the current recommendation recommendation, a uh well follow in France. And because it's uh we recommended actively preventing fever, uh I post cardiac express with Roman tomatoes. But uh you can see also that this uh is issue from the editorial after the danke paper. And because the study was considered as negative uh via asks what the target temperature could be uh might be at the decision of the clinician 3336 or 37.5. And you can see that approximately 16% of the French center use still use modern telepathic hypothermia. Uh You can see here the distribution according to the R and the duration of CPR. Uh This is very simple. The first two A re a checkable uh read with a CPR less or higher than 20 minutes. And uh in the bottom, you can see non checkable read uh less than 30 minutes and higher than 20 minutes. And you can observe that there is no uh differences concerning the distribution of temperature uh in this uh group of patients. And this also is associated with the recommendation. The recommend are that there is currently insufficient evidence to recommend for against temperature control between 32 and 36 in some sub population of patients of CAAC arrest. And this needs further, further research. Uh We also ask some question concerning the uh techniques to uh maintain temperature control. And uh you can observe here a change from 15 to 33 B uh that concern the use of att M with temperature feedback device. And you can observe as the use of uh device with temperature feedback markedly increase between 15 and 33. You know that the recommendation uh that you can uh manage tt min using an in exposing the patient. This is surprising for me in using anti drugs or this is uh of I if it is insufficient by using a cooling uh device and uh the statements um it's my opinion uh should be discussed and because there is some uh I can say proof uh I be some evidence that favor the use of devices with temperature feedback, at least to improve the neurology, prognosis as described in this slide. And uh we have a look at the at the center and we found that uh center that are more likely to use the device with temperature uh feedback are more likely to work in a university hospital. They admitted more cardiac arrest per year and they have in the very next to the IC U uh no speed cat lab that is able to perform a coronary gray. So a very big center generally in a public uh university uh center, we also perform a nurse survey and uh some uh interesting point might be highlighted first on the left part of the slide. You can see that uh uh majority of the nurse have used at least on uh device to control temperature. But they are also uh they also use the IC U some old fashioned techniques to TT M such as Colin or cold water bath. So this act for heterogeneity in Center Practice and on the right part, you can see the answer in green. Yes and brown or nuance of brown. No, that uh the opinion of nurse on TT M device and special TT M device uh with uh temperature feedback. And uh they uh agree for a great part that when they use att M device with uh feedback, it's quickly effective, which is uh I think very important and it's easy to manage, easy to tune. Of course, because it's efficient, it makes fever difficult to detect. But is it very important if we want to control the temperature to detect the fever maybe to add some antibiotics, for example. And I think this, it is also an important point. It makes more difficult. This is a tech technical point that may be may be improved for the future. My conclusion concerning TI a second part in this presentation that concern general management of CAS first in France, currently very good a question to the current recommendation. And of course, the TT M two trial publication as in use, a modification of current practice. Uh majority of clinicians in France use TT M. Uh currently moderate apo or therapeutic hypothermia is used less frequently when compared to 15 with red decrease from 62 to 17% approximately 60% of the respondent use the uh device with uh temperature feedback. Nurses globally have to manage various methods for temperature control in the same center. In the same I they found that TT M with a temperature feedback is rapidly effective, is easy to adjust. But it is associated also with more challenges in terms of daily nursing care. And this was not presented. They found that the majority of nurses found that the procedure for withholding or wh holding life support therapy is generally so a good agreement between the nurses and the physician. We also ask some questions concerning the general first, the neuralation on the right path. You can see the current guidelines and five main items were identified but are likely to be associated with poor prognosis. And you can observe in green that these items are generally followed by the French Tunisian, especially the absence of brain stem reflex status mio the use of presence of malignant, uh the use of uh neuron specific and uh in less proportion, the use of uh neuro imaging especially uh MRI which is uh less used uh concerning the coronary angiography, of course, uh uh patient with uh s elevation after the cardiac s generally have a coronial gray and in the absence of ST elevation, how can generally use what is generally proposed impacts on eco the presence of konic shock. And you can observe that. And this is new that in non shock, the incidence of geography is now very, very small. This slide is difficult to interpret because the accommodations are very large but you can observe that min pressure, which is a point that should be discussed. Should we individualize min pressure in patients with cardiac? Originally use pressure, I have 65 which is recommended for us Oron shock but no specificity for cardiac arrest. Some interesting point concerning the sedation and analgesia. First, it is recommended to use short heart drugs such as propofol. And I do not put the the difference between 15 and 43 but the use of propofol is increasing. Uh but uh you can observe also that uh mita which is clearly not a short outing drugs is still using a high proportion in our patient. The place of allergenic gas is near zero for at this time. And if we consider uh Morin memetic Rifan, which is a drug with a very, very short art life is used but less used than fentaNYL or fentaNYL uh treatment of seizure. No further comments generally. Uh the recommendation that a re not specific to KRSARE generally follow. And my conclusion concerning the ma summarising concerning the general treatments uh uh along TT M is that we follow. Well, the indication for colour gray, we observe an higher use of propofol. But midazolam is still use target values for two blood pressure are generally consistent in the current guideline. It's the same for neuralation and maybe a negative point which is I don't know if it is specific to France, but we have a law and the law said that we have to obtain a second opinion from a physician who is not involved in the patient care. And this is not follow in approximately 30% of the cases, which is not very, very good. Thank you. Thank you very much for your attention. Created by
