Transcript Video Patient Populations and Those Left BehindDr. Carl Hinrichs < Back to Boundaries of Temperature Session 2: The Patient Patient Populations and Those Left Behind Presented by Dr. Carl Hinrichs now I announced dr Carl Henry's he's a senior physician at the department of Internal medicine and nephrology. An intensive care unit at the University hospital charity here in Berlin. And he is a specialist and has very interest in A. I. Research. But at the other hand he is part of the charity cardiac arrest center team which implemented ti tms. Standard care in the I. C. U. S. And participate in in the T. T. M. One and two trials. Please talk to Hillary's. Yeah thanks for the nice introduction and um it's great to be here. Um I guess I'm one of the lucky guys who hadn't problems to get here because I just had to pick a cap. Um So in my talk um it's titled patient population and those left behind I put my email address so whenever there are questions um just just write me and I'll be glad to answer um outline of my talk. I just got to two topics. One is brief introduction or standard of care and after tragic arrest and the second one as a result of the T. T. M. To trial which is has a major impact on the uh resuscitation community. And the conclusion we draw from it at our very center. Okay start with our standard of care. Make a long story short we do 33° for all out of hospital cardiac arrest and we have a. S. A. P. Based standards. Okay we try to onset T. T. M. As soon as possible we do 24 hours and um rewarming with 0.25 degrees per hour. We slow down If the patient shows signs of thermodynamic compromise sometimes that happens. Um And it normally takes about 16 hours to cool them to to warm them up. Day three we've got a your prognosis work up based on SCP. Um You're on specific Enola S. E. G. Cat scan. And as the results at day 372 hours and conclusively repeat some of the exams together basis for um therapeutic decision if patients show signs of um bradycardia with thermodynamic compromise and only then we adapt temperature. So some patients tolerate 34 degrees uh better than 33 or 30 35 degrees. But as my as professor pointed out we care for keeping temperature target temperature um in a range. So we use service cooling and we use the feed feedback device. Um We put some effort and prevention of shivering. We heard already that this is important issue in hypothermia. We do it by caring for deep sedated patients in the hypothermic phase. And we apply counter warming measures which means socks and gloves for the patients and uh in interest patrick cardiac arrests. Um We do T. T. M. Depending on patient's history. Some patients with very short no flow. No full time. We don't apply t. T. M. But if a patient arrives from normal ward um Normally we do T. T. M. For them as well. Then came T. T. M. To trial. And that questions our S. O. P. M. And as we heard before there were discussions in our cleaning as well. Um But then we stick to T. T. M. And we stick to 33 degrees. And in the second part of my talk I explain why um yeah we are already T. T. M. Tutwiler large multi centric multinational trial and failed to um to find the difference regardless whether you do hypothermia or the term normal samia. What they did in this trial is a randomized 1900 patients one on one to hypothermia which means 33 degree as an hour center. Um Normal Samir. That basically means prevention of fever. They assessed the patients after six months and they didn't find the difference between uh both patient groups neither in survival nor in functional outcome which is for intensive care a specialist, maybe the even more patient centered outcome parameter. They used the modified Rankin scale for the assessment of functional outcome. When you look at studies with the negative results you have to think why the study failed to to show the hypothesis to meet the primary hypothesis and um plain Pelini. Um At first it could be simpler reason that the intervention doesn't work. Um But when you look deeply more deeply in in these studies there might be other reasons. So there's just just an hypothetical curve patient disproportion of a generic risk factor and you always have on the right side some patients which are too good to benefit from whatever intervention you do could be t t m in the cardiac arrest population. But whatever medical treatment treatment you apply to whatever patient cohort on the other side, you got this with markets too, a patient cohort which won't benefit because they're to bet. Yeah, in the if you work and I see you you see people dying whatever you do relevant proportion of patients after cardiac arrest actually, um and TDM won't do any good for them because they die from other reasons as they might even die from hypoxic brain damage. But initial impact might be so. Um So the idea that they doesn't have the chance to benefit from any post um initial treatment. But in between those extreme poles, y'all still got a large population of patients which might benefit. Um And if you choose your patient population for study, um in a certain way, you might just miss this patient population who will benefit from this um treatment especially. So, but what they basically did in the TPM trial and the screen of um Um very many patients with the queens have screened over 4000 patients, but um over half of them were excluded before randomization for some reason, some some of them are technical. Um but still there are some reasons that are relevant medical conditions for categories of patients. So they excluded patients with presumably non cardiac cause of arrest. The large proportion over 400 patients unwillingness to others too and severe COPD totaling to over 600 patients from relevant patient population which weren't included in this trial. Um And what they basically did, they increased population which we are at lower risk for um hypoxic ischemic brain injury than the general population. We see at our center. When you look at data from our center, just from 2018, It's about 250 patients and not as many as we could have done, but we were dealing with this little panda mia of us in the recent times. Um But when you look at the white side of the chart, um there's an acute coronary syndrome as a but right besides that, we got a large proportion of patients who had cardiac arrest because non of a non cardiac circulatory arrest because of non cardiac reason they're all out of hospital cardiac arrest. And only patients who arrived after returners of um spontaneous circulation. No patients from our more program. So as you can see for us the non cardiac cost of the category best um relevant patient population um which weren't addressed in the t t m to trial. It isn't that we don't know anything about these patients. This is the study. Um um with target temperature management for cardiac arrest with non chargeable realism among these. There are also patients with cardiac cause of circulatory arrest but still non cardiac causes more often leave to P. A. Or and they did find a difference between CPC scores um in the hypothermia group um patient um with good neurological outcome CPC one and two was nearly twice as many as in the normal c'mere group. The choice of patients is reflected in the patient demographic of the TTM to trial. So when you know, you take a look at the reason you see that about 75% of patients had a shock rhythm to primarily a better prognosis than the the other groups. And Moreover, you see astonishing behind number of Bystander Witness. Carmichael rest over 90%. We have 80% in our patient population. Which is for me it seems to be quite high actually, but that's that's the data but that means that we have twice as many unwitting nist out of hospital cardiac arrest than in the DTM tooth while And even more astonishing. They had um 80% of patients were bystander CPR. Um The reason for that it's um T. T. M. Two is basically a Scandinavian study and therefore um Sweden was one of the strongest n roller in uh within europe. It's a country with only 88 million people. But still they enrolled over 400 patients of these 202 thousands. And in Sweden you learn CpR at school at elementary school they start to teach CPR and they go on with it during school time in Berlin you're learning CPR when you need CpR to be done. So basically the fire department if you call the fire department with the patient with category rest, you've got telephone assisted CPR. So um Lehman is advised how to do CPR and that's how bystander CpR is performed in most times in Berlin. I like this project from the Berlin Fire department but still it can't replace teaching CPR at elementary school. Um going through my slides yesterday in the evening I got distracted by this newspaper articles from the Berlin local newspaper and for the international audience the headline is um survival rates after cardiac arrest in Berlin is lower than in other in other cities. And they referred to two cities like Park and Copenhagen. And in this newspaper article from from yesterday Berlin Fire Department reported bystander Cpr rates of 38%. The center we see a little bit more because we only see a survivor of of CPR but doesn't reach 80% as in the DTM to trial and that has an impact on the prognosis of our patients. Just to remind you that CPR quality matters. Um there's a data from 22 small studies with educated personal. I'm doing CpR and we see on the left side there's a depth of cardiac chest compressions has an impact on survival and on the right side that the frequency of chest compression has an impact on survival. And that demonstrated also in the educated professionals quality of cpr various and that had a direct impact on prognosis um in a um if you you some stepped up you have a um in the T. T. M. To the patient collect um collective uh you have most probably a high rate of patients who are underwent high quality and Cpr with a rapid onset. And that gives us from data from our center. Another study, it's from 222 from uh uh um it's not a randomized control study but anyway I think it's kind of striking. Uh they just correlated the effectiveness of um uh T. T. M. Uh with the rate of bystander Cpr reported in the respective study and they found um negative correlation between rates of bystander Cpr um and effectiveness of target temperature management which underlines the importance of um the risk population at risk when you do these studies. So I'm a little bit ahead of time. So I've got um the opportunity to to show what happened at our center when we changed from normal premiere to hypothermia can't control you the opposite because we uh we didn't change our protocol for now and it's an historic um comparison. So it's not a randomized control trial but but yet it's our patients. It's our most relevant patient population we can can imagine and we see on the white side um um the good functional outcome blue and green CPC one CPC to increase dramatically when you compare them to the pre hypothermia period proportion of deaths after cardiac arrest doesn't change too much because as I pointed out um the reasons for deaths um um diverse after after cardiac arrest but neurological outcome changed dramatically. Again. Historical comparison. Um You have to be careful to draw any conclusions but still for us. Um It stays relevant information that we have for my conclusions. Um After all these T. Tm studies we have to admit that I'm normal T mia seems to be safe and circular arrest. Um Normal Tamia doesn't mean whatever temperature you do but um controlled normal body temperature. This is what most studies were evaluated and it seems to be safe in patients who had observed cardiac arrest. And the high quality bystander cpR patient collectors. We want um applying um T. Tm two tm. Um anyway like short period of CpR on ICU or during an intervention. Um We haven't done T. T. M. Before however um stopping T. Tm after the T. T. M. To trial would be dangerous because we don't have any information on patients who have a higher risk of hypoxic ischemic brain damage. And uh patients who might specifically benefit from cerebral protective therapy. And what we still need is the T. T. M. Choir which tells us what to do with our patients in central europe. Um Yeah and that's the end of my talk and I would be glad to answer your questions in the end. Created by
