< Back to Summit23
Brain Injury Management
Panel Discussion: Brain Injury Management
Presented by Professor Bruno Levy, Associate Professor Per Nordberg, Dr. Andrew Foulkes, Professor Christian Hassager, Professor Richard Ferrer & Dr. Pablo Jorge Perez
Moderated by Dr. Thomas Pellis
And now I it's my pleasure to invite you all uh all the speakers of this panel on the stage. I am really impressed. Um I was afraid in the, at the beginning of this morning that we were not delivering a clear message to you. A take home message. I was absolutely wrong. You're not alone with confused laboratory or experimental data. I can, I can say uh this session has brought you clear messages and has led you if I can summarize from um a a in a survey of what's really happening in our IC U. And what is the difference between guidelines and real life to ways we can standardize things for you in terms of scientific societies and make it easily pre digested and available for you and then how we can escalate to a systemic level, getting to the point of accreditation. And if you think these are, this is a translational model from other areas of medicine. So, labs have to be certified. If you wanna do cutting edge things like RT cells, you have to be accredited. So uh and then not to forget upcoming frontiers of research. So I think this is an excellent opportunity for you to feed in. Raise the hand, ask for a microphone or send me in questions on the ipad and I'll transfer them to the, to the panel. So uh I wanted to have it AAA conversation which was down to the ground, but I think you did an excellent work. So I'll throw the ball in your side of the field and ask you, is there anything you would like to ask each other to, to break the ice while I gather the information from the audience? Please start start uh Pablo. OK. I see. You're excited so I can do it. I can do it. I, I would, I would ask, I would like to ask to pair if you think that next trial are gonna give us uh real positive results in terms of uh temperature control. Do you really think that this strategy, for example, for Princess Two is gonna give us the answer that we are waiting for? I hope so, but it's so difficult to give you an answer there. Of course. But I think um I think we need to challenge ourselves to move into a, you know, not only do pragmatic clinical studies but to do them in the way that we know that path pathophysiology is, is in cardiac arrest, to, to really protect the brain. We have to, to find out really good ways to, to, to study what, what could be neuroprotective and I think when it comes to cooling, I think you have to start really early with the, with the effective method. So we'll see in a couple of years if uh if you were right. Yeah, any questions between you. No. So I'll take the lead then. So um per I keep getting questions on how to join the trials. So the step care uh if you are one of the collectors of the step Care trial, if you can uh send a message to the audience of how to get to you, reach to you or to the step care, the step care trial. I'm not, I'm not uh involved in the step care trial in that as an active recruiter. Uh because we're moving the other way with the early cooling and, but you can find the, the contact information, step care.org. Um If you wanna step care.org or Kiara Robba is among the uh participants at this conference and she's the national uh investigator for the Step Care trial in Italy, at least, but at least from her, you can get to your national coordinator. So one thing that was very interesting is that we now are surfing above temperature control. Temperature control is just one ingredient of resuscitation care. And now we are moving to a higher level in which we integrate temperature control, we leave it open with its uncertainties, but we integrate it into a more robust and structured approach, right? So I really really enjoyed it and, and, and I, I don't think we should limit ourselves to the uh to the um question of whether it works or it doesn't work because if you think about it, um assistant device for mechanical failure are, are having a, are struggling to provide evidence that they work. But something like ECMO undoubtedly works, right? Somehow keeps the circulation going, but then we have to translate it to clinical practice. So uh I think this is a, a great example. But if you wanna comment on that Christian, I would just, I I fully agree that it's prob what that's why we try to do a uh equality indicators all the way from the patient uh drops down till he is three months ahead from this uh whole journey there. And I still would like to really highlight that if we should have a chance to treat these patients at the hospital, the pre hospitals, even even before the ambulance arrives is very important. Otherwise, the patient are too damaged for us to really do a change. I think. So we should really work at having the public uh to help each other because we can never build a National Ambulance Service that can go everywhere uh within five minutes. I mean, that would be too expensive. So we have to, we have to change the whole idea in the society if we really want to move this. And then on top of that, I think the IC U treatment is important, but we should not forget the pre hospitals phase, the very early phase. And in that sense, probably the Princess trial is again, very provocative, very, very great, but still in order to be positive, he is also depending on you and you and you that you do lay cpr early because you have to get in, you have to help them as early as possible. So this is AAA strong political view. This is actually the chain of survival, right? Yes. So you're all the links in this chain which cannot be separated because singularly they wouldn't work. Yeah. But it, I mean in Spain, for example, uh we are working in in Caracara Center, as we mentioned. But uh one of the main strategy of the project is to to go to the ministry, Ministry of Health just to incorporate the project. This our project not only uh focus on c centers, the ministry uh has uh uh cardiovascular strategy for uh for uh cardiac arrest, out of hospital, cardiac arrest. And this is only one of the of the of the stones, small stones, but the whole project of the ministry is to improve bystander CPR. And for example, I think each category center in Spain that sh that wants to be certified should know how, what's going on in the community, what's going on? How is the percentage of bystander Cpr in my area? I know that my in in Tenerife is less than 50%. So probably uh having a category center, we can improve a little bit, but we we have to go to improve by standard CPR as category centers with local governments to try to uh develop strategies to improve that in schools and all things that Ben She said before. So I think each category centers should know what's happening in the community to try to improve bystander CPR. I mean, these are the giants we should stand on top of, right. So you, you see the example of Denmark, which should be our path, our lead to the future in Europe, at least, right? This should be taken as an example. Uh Sweden has shown that with an app, you can improve recruitment at in real time for a cardiac arrest victim and the defibrillator. And then on, we are getting to the ways you can uh push to improve and standardize implementation. So I think we, we said this over and over. Um Now I I was promising myself not to touch this topic, but I, I will spice up the conversation and pretend we are not in a industry driven conference and go to the presentation of Ricard in which there is a very interesting signal. Um As a matter of fact, I have to confess my next conference I need to give a talk to is uh and I haven't of course prepared. My presentation is to politicians basically to run on a regional level, a program. So I have to convince them that what we do on the field until recovery. And I'm very pleased to be moderating such a session now. And I will ask you slides has an impact and to have an economical review of what we do is very, very important, I think. Right? So surprisingly, II, I was very surprised to hear that one of the signals is linked to a device which per se we're not sure how, how can do the miracle, right? But I have to confess in my real life, uh I I can see that whenever we don't open the package of post resuscitation care and the device is certainly a big flag that stands by the bed of our patient. Then things get mixed up, you know, we lose momentum, we lose that focused approach that we have. Can you comment on that? So I if I have to address the politicians are two topics that are very important, which is accessibility and equity. So they do really, which is the network of centers they have in their area that are really providing good care. Probably not, probably not. And they have to be sure that all citizens have access to one of these type of centers. So this is uh this is important and and the other important thing is that it's clearly demonstrated that if you provide the adequate care, you reduce the long term sequela and this is in terms in economic terms, this is very cost effective, especially because of the indirect, indirect cost and the social cost of that. So I think those are the the the most important topic. So access to the system equity to everyone and then uh try to avoid long term secu and this is very cost effective. Uh This is the way we are approaching this in Spain. And why do you think a device stand up stands up in your analysis for that? Uh Oh I, I insist that this is uh a sub subjective evaluation. So this that are not coming from an audit, from a observational study is coming from a survey. So there is always a question mark but it could be because of the effect of the device but also could be a marker that the global care is better that in that center, they have a good protocol and a good uh and a uh a very well organized process of care. So Bruno, do you have a comment on all we said so far that you wanna add? Yes, I have comments. My main uh interrogation is about the use of uh uh tt M without any device. And I'm very surprised because I find it very, very difficult in a practical point of view. And the nurse highlight this point and I know there's been some cost reason for that, for example. But I, in my opinion, it's impossible to obtain a real TTM without any device with a feedback control. Iii I thought your presentation was, was, was very interesting, especially with the burden of what we ask our uh our personnel to do and what is their perception of what we are doing and how we're doing it and how we could improve it? Andrew. Do you have a comment to add before I come to the questions of the audience? Yeah, I just think we're aiming for offering advice to units even if they don't have a device because we're trying to encourage people to start thinking about improving that care. Now accepting that resources are not always as much as we'd want them to be so that people can start driving that change forward and that maybe actually protocols that point of the care will help to drive that case to make, to extract the resources you need from your administrators to get devices. So I I have a few questions on, on um for example, metabolism of drugs. Are you concerned to to give an additional point of view? In that uh topic we are discussing now with Bruno is about connected medical devices. So all the devices we have in the IC U are supporting or monitoring the patient are connected medical devices, producing data that are useful for taking decisions of patient management. Maybe for research. I think that nowadays it is not acceptable to do an intervention that cannot measure uh uh the intensity, the dose of what we are doing. Uh I, I think it's not acceptable in an IC U right now. So we have to measure everything and we have the data of everything we do and it's not acceptable of doing cooling without a device. I think it's, it's uh I mean, we are doing everything with connected medical devices and, and gathering data of everything. We are doing a comment on drug metabolism and temperature control. When you lower the temperature, do the drugs work worse or do they accumulate a common? If we refer to a physio paper, generally for temperature of 44 there is no major uh change uh for the for drug, especially for, for drugs or for coagulation in the I think in the sa me, some slight decrease in platts uh efficiency for exa mples. But uh 30 f 34 s what we call moderate hypothermia seems to be not detrimental. And uh if we look a T the TT M two, we only uh we observe some increase in arrhythmia, which I think is not a major side effects. We a re just to increase the temperature and uh we can start for hypothermia and to increase if we, if we didnt need for exa MP. So the using drugs with a a very short metabolism but just to, to come back to the subject of uh of the device, I'm very surprised by the recommendation because I understand that the recommendation is for the world and uh depends on the economic level of the the country, but maybe a good recommendation should have been uh uh device which a re recommended. But we you can also uh use if the if uh this device a re not available over techniques. I think for uh a t least for Europe, it's good. I understand that in some uh uh country, it might be difficult to, to, to pay for this device. But uh I think it's a better recommendation and uh suggest to, to change it my Children. So uh we I still get questions on what um in which kind of cardiac arrest should we control temperature. So maybe we can give a message to help the audience since this is still coming in. Uh as a question, unsolved questions for short cardiac arrest. Would you monitor, would you control temperature if the patient is in coma? I would that's the answer. So it's not the time of rest is the condition of the patient that leads the the therapeutic strategy. And then a a a case which uh someone has fed in to know your opinion on this. It's a little bit off topic as a premise. But the uh the participant would like to know um if you would use a cooling device to obtain pneumo theia in someone who is in cardiogenic shock, improving stables. So, so as to say, stable on inotropes and that is developing fever, is developing fever without signs of infection. Now, this is another interesting topic. We we have not mentioned that clearly, but it's very hard to define why you're having fever after 48 40 hours, 48 hours, since most of your markers are somehow confused, right? So Christian, so we're dealing with a patient who has not had cardiac arrest, but who has had cardiac arrest, cardiogenic shock. You stabilize his hemodynamics though, with drugs and now you're facing fever, would you control his temperature? And how would you do it? If not the way we, I can tell you how we do it. Actually, we add a cooling catheter to all patients and then the nurse is supposed to uh turn on the machine. If the temperature goes up about 30 37.5 the uh the most of our patients because of the protocol that they receive probably uh receive some norephinephrine. Most of the patients. I think about 90% of our patient have some basal active drug in, in, in within the first period. As I showed you the data there in our population. The uh we did not see any reason to go beyond 36 hours. I know the guidelines say 72 hours and I should highlight that here that the guideline says that if the, if the patient get fever 48 hours out, keep it down yet until 72 hours, we don't do that anymore. At my institution, we follow our scientific data and say that it's OK to stop after 36 hours. So we have a counter down here that you cannot see and it's sticking low. We have maybe we've already overshooted actually. Um But I think if I can summarize what you say is that the approach they have is reactive. But actually, it's also proactive because you insert a catheter because you know that at some point these patients might require your assistance and you want to be fast at that time point, we don't want to call a doctor who should put in a new catheter or something like that and then it takes hours. So, so we make everything ready when the patient comes in and then the nurses are ready to, then I can sleep and the nurses can do the job. OK. So this is a good advice for survival in the IC U. And with that, I think that our time is over. So I would thank the panel. Uh So a big round of applause for them.
