Transcript Video The Drugs Don't Work, They Just Make it WorseDr. Edoardo Picetti < Back to Boundaries of Temperature Session 5: Control The Drugs Don't Work, They Just Make it Worse Presented by Dr. Edoardo Picetti we come to the last lecture before lunch dr. Eduardo. He's an anesthesiologist and intensive ist working at the intensive care unit of Parma University hospital. And he has studied the effects of anti pirate ticks in many clinical studies. And he will summarize his works today please. Good morning to everybody. Many thanks for the organizer for my invitation at this beautiful meeting. And the the topic of my presentation is the utilization of antibiotics Inside a team strategy. And more specifically I try to discuss with you about the utilization of antibiotics in in patients without cardiac arrest. But we've had to bring injury trauma to celebrate the mortgage etcetera. And in patients with cardiac arrest some definition the definition of DTM is very difficult. It is more difficult after the publication of the DTM to trial but 40 tm you can consider a number of protective complex intervention utilized to minimize the secondary neurological injury and to improve neurological outcome and and compass therapeutic hypothermia. Controller norma termina and the treatment of fever fever is a dangerous secondary insult for the injury brain. There are several mechanisms that may be dangerous for the brain. And this association has been demonstrated in patients with TB. I impatiently struck in the cardiac arrest population and also this phenomenon rebound hypothermia is associated with increased mortality with bad neurological outcome. Antibiotics are a drug that are utilized to treat fever, paracetamol and diclofenac sodium. Are the drugs that are utilized more frequently in the setting of the Nower patient probably in some part of the world that are also different drug such as meta missile in my country is not available. But this drug the most utilized in the I. C. U. These are the characteristics of these antibiotics now regarding T. T. M. Antibiotics, a patient without cardiac arrest. So patients with traumatic brain injury with stroke. Anti pirating can be administered by intermittent by continuous intermittent can include intravenous such as paracetamol. The intravenous formulation of diclofenac sodium is not worldwide available intra muscularly the and by mouth in the naso gastric tube paracetamol and regarding the continuous infusion. The only data available is for the cloth and sodium. This is a little study that I have performed in patients with brain injury. In this category of patients. The administration of paracetamol is effective in the control fever is associated with a statistically significant reduction in CPP in military pressure and also the proportion of patients that need Vasso pressure is increasing. This is a physiologic side effect of antibiotics that every physician should keep in mind to avoid another secondary insult to danger. Brain paracetamol can be administered also by mouth or by erectile and disease. A study involving active chemistry occupation with you in to celebrate the marriage. And also in this case is the administration of paracetamol is associated with a statistically significant reduction in arterial blood pressure. This study shows the utilization of full dose of the cloth and sodium administering near 30 minutes is very important this time. This dosage in patients with subarachnoid emerge in this category of patients. The administration of the cloth is effective for the control fever is associated with a significant drop in brain tissue was monitoring and in CPP this is another study we in which the cloth paracetamol are utilized as as antibiotics. Also in this case the utilization of every but this anti Pirated by single infusion, not not by continuing fusion is associated with a significant drop in arterial blood pressure. This is a study regarding the cloth and administered by intramuscular in my department. This is a frequent route of administration of the at the very low dosage, 12.5 million grandma and the at this low dosage is very effective in the control of fever. Also in this case the administration of the cloth is associated with a reduction in arterial blood pressure is a physiological reduction because to dissipate it you need to be so delighted. The fact of anti pathetic is vaso dilatation. Its physiology is normal. And this is the only study small, very small study regarding the intravenous continuous administration of diclofenac. This is the only study in which the continuous infusion of very low dose of diclofenac is not associated with hypertension or with an increase in. But this is a very small study. More research is needed in this field regarding utilization of anti piratey. In the post cardiac arrest. I refer to T. TM one TM two trial regarding the T. T. M. Trial. The big change that in my opinion is related to the study is the control of temperature. This only related to the 1st 24 hours, but the control of temperature was performed for the first free day after cardiac arrest. This is a very important message of this study and in this case after the 1st 24 hour. In some cases when you don't have a device, antibiotics are utilized but there are no data about the type of antibiotics and the side effects anti pirating in this study. The same is for the to trial. And obviously The main problem with the is this that patients in the norm? Attorney a group more than 36% of patients. The norm. Attorney a group say the cooling with advice. So exposure reduction in ambient temperature. Anti pirate is clearly not effective in a strict control of the temperature. But that about the type of antibiotics utilizing was not available in this study. This is the recommendation that are published after the T. T. M. A. Trial that I think you know and now what is the role of antibiotics inside addiction strategy Before to start. It is important to be aware of the lack of robust data from well powered randomized controlled trial. There are no randomized controlled tire regarding utilization of antibiotic, impatient with equity. Bring injury in the post cardiac arrest patient. Your objective, our objective is to treat the brain monitoring the brain is not so easy in all patients because in some center there are not monitoring in cardiac arrest patients who have invasive. Now monitoring is very difficult. So the personalization of therapy is very important for every patient in the post cardiac arrest phase and inequity brain injury. And also the costs are very important because some form of monitoring some device are not available worldwide. And this is a survey that I have done with the european society of intensive care medicine. There are also a great variability in the definition of fever in the monitoring of fever in the treatment of fever. And this is very important to keep in mind this aspect when you don't study in this field regarding the neuro critical care setting in patients with active brain injury. Be aware of the different in in between the core temperature, the brain temperature in the normal term miA. During fever I utilized, I suggested to utilize them this uh drug or this device. Considering the resistance of fever but also the presence of intracranial hypertension or the cerebral ischemia. So in this scenario, it is not necessary to start in my opinion without device because generally to have a monitoring for equity brain injury patient is more easy that you have an invested monetary or a credible monitoring as in the cardiac arrest patient. Okay, so in this case the utilization of drug or device for the control of the temperature need to be considering considering the brain media. So the presence of pretension and the presence of cerebral ischemia regarding cardiac arrest. If you have a device, I suggest you to utilize the device. The device needs to be utilized probably for the first free day, but but also after the first three day. It depends from the condition of the patient, not all patients awake after three day. And it is important to consider some form on our monitoring, imaging A. G nears and in some cases there are. This is a very beautiful article showing the feasibility of investing in our monitoring in patients after cardiac arrest. In this case, we can look inside the brain, we can modulate therapy the character modern if you don't have a device because you don't have money. My suggestion is to utilize drug and physical method for favor control and also to consider narrow monitoring to consider and also the possible side effect of the drug. The liver toxicity for paracetamol, the gastric or any toxicity for the and the effect of drugs on the arterial blood pressure. That may be very important in the post cardiac arrest patient. And another aspect they need to be considered is the fever probably is dangerous for the brain, not only in the first three day after cardiac arrest. And it is a field of research for, for the future, in my opinion, to prospectively analyze the impact of fever in patients after cardiac arrest beyond the first three days. And another interesting aspect is that antibiotics is not only utilized for the control of temperature. Some anti pirating can have anti inflammatory property, so you can have a cardiac arrest. You have a delayed inflammatory response related to ischemia profusion injury. So this is an important aspect that in my opinion need to be investigated in the future. So in conclusion, in my opinion, in patient with extra brain injury without cardiac arrest, anti pirating can never roll, especially inside a staircase approach to fever, such as a staircase approach to intracranial potential. And please consider side effects of antibiotics regarding cardiac arrest. I think that anti pirates can even roll if you don't have a device. Also in this case, please consider side effect can have a role in case of the live fever. And for the future anti priorities can be combined with our device not only to control shivering, but also for the potential never protective effect. Thank you very much for your attention Created by
