Transcript Video We Need Protocolized Care < Back to Summit23 Brain Injury Management We Need Protocolized Care Presented by Dr. Andrew Foulkes So, a bright future is on the way with Maura to debate for the upcoming conferences. And now it's my pleasure to introduce Andrew folks. Andrew works in uh uh Clyde Hospital. He's a consultant in intensive care and anesthesia for the card arrest regional center. But most of all uh Andrew works is part of the echo consensus uh for the use of temperature control for subarach hemorrhage IC H and acute ischemic stroke. And recently chaired the UK and Ireland Consensus on the practical implementation of uh uh hypothermia for cardiac arrest and actually cardiac arrest guidelines. And that's his topic, right? So he will be giving us a lecture on the fact that we need protocol I care. Thanks. So yes, I have a um checkered history in different consultant jobs through my career in intensive care. But I've worked half of the time in Neo I and then moved to Glan Clwyd Hospital in Wales where I work in general. I but in a center that has a primary PCI center as well, all I can say about the rest of my job is don't choose to manage surgeons if you have the choice we met with the support BD as a panel to try to produce something that a practical tool for units that don't currently practice that much TTM or are looking to start introducing it so that we can offer people a way forward to having guidelines and implementing them as effectively as possible. There's a group of six of us with a variety of backgrounds, some of us with experience in Cardiff and Nero but all with a view to general ICU. And the aim behind this is not to produce a protocol that everybody should follow in every unit. It's to produce something that units can take as a simple get you started guide to come up with their own local guidelines. See lots of intensive care units have different levels of experience and we want to encourage people to follow best practice, but also people need to come up with something that works for them and starting everything from scratch. If you have no experience in your unit is not something that you have to do when there's other people out there with more experience. But also it can be very time consuming to go through that training curve with your staff, especially in the we have high turnover of nurses in our unit. Especially guidelines need to be pragmatic for local circumstances by which I mean, usually trying to herd together a group of your consultants to agree on something. And obviously, that's no great achievement for a lot of people. But if you can get your consultant group and your senior nursing staff to agree on something locally and then promote using that in everyday practice, you're far more likely to achieve something. So we're looking at units that newly implementing temperature management or upgrading their provision to feedback control systems. I want to give them an easier path to developing a guideline that they're all prepared to agree on and implements as much as they can of best practice and recent evidence. All of us meeting at this group have significant experience with cardiac arrest patients usually in high volume centers. The over 50 a year group, the rationale is, you know, has been explained to you at much greater length by far more experienced people than me over the course of this meeting. So I don't need to go into the background of that, but it is still the only treatment recommended for neuroprotection by the a the methods and how you implement it though. It will affect the effectiveness of the treatment. You deliver any potential for improvement in outcomes, some effect on the disadvantages and risks. And certainly the demand on the staffing time that you have on your unit. We've all got a lot of other patients to treat as well. And in the end, this is a subset of them, those of us lucky enough to have practice development nurses who can train our junior staff. They have an awful lot to get through. So there are three approaches that we talked about. There's preventing pyrexia, there's maintaining normothermia or there's inducing hypothermia. And we're not aiming to recommend one over the other. It's about choosing something that you can agree on locally and moving forward with it. What we do acknowledge is that approaches have varied over the last few years, especially since publication of TTM one. And we've seen decline in the use of TTM and arguably in outcomes that follow as well. Many guidelines pre date, the outcomes of TTM two and the world has had quite a lot to do in intensive care in other realms in the years since TTM two came out. But hopefully, we're all starting to look a little bit beyond that. Now, both of these trials cast doubt on the value of hypothermia. But of course, there are many other trials now in progress which may well give us a lot more news on that in the years ahead. So we had an in person meeting in March this year with the assistance of a medical writing company and an independent moderator to try and herd us into coming to some uniform opinion by the end of the day. And we went through the key topics that we felt needed to be on a simple one page guide with the aim to circulate that eventually to units around the UK. We brought our own cardiac arrest protocols, all of which vary substantially and don't just cover temperature management. And then we worked through this into an edited draft and we've prepared a submission which is still in publication at the moment. So we defined the patient group covered that's out of hospital cardiac arrests. But we haven't been didactic about that in our recommendations either because most of us work in units where we've ended up implementing temperature management on in hospital cardiac arrest and other patients as well. But it certainly starts with the evidence base. So we covered our own approaches to temperature management, post cardiac arrest. We talked in some detail about how we approach rewarming because it tends to be seen as one of the more tricky phases where there are occasional pitfalls. And we want people to know what they're looking for. And then finally about use of temperature management during that neurop prognostication phase as we get towards 72 hours. So we agreed a final draft in June this year, we've given written recommendations as a 23 page article and a one page summary guide, which is what we're looking to circulate. Two of us have an affiliation to Wales. So we've discussed that with our National Intensive Care Society and they've endorsed it and we're awaiting a decision from the UK Intensive Care Society in their journal as to publication. Hopefully we'll know about that in a couple of months' time. So the key recommendations, temperature control to start as soon as possible and that's really to promote people thinking when you're developing a local guideline about what are your local barriers? Obviously, if you can implement in 19 minutes, that would be fantastic. But we've all got very different hospital set ups. And unfortunately, with the best will in the world, if you're a 10 minute walk with a trolley away from Ed to it, then you're unlikely to get that. And most of us are still working on implementation in the order of two hours. But the encouragement is simply do this as fast as possible. Use of a continuous feedback with a closed loop device is what we'd recommend. That's obviously not a great surprise. But what I would say is we've tried to make this about use of temperature management even if you don't have a device because there's still lots you can do for your patients by protocols. This the method of temperature measurement, a continuance measurement of core temperature is essential. And again, doesn't have to matter whether you're using a continuous feedback device. Obviously, if you are, then there's no way you can use one without bladder or esophageal probes are acceptable. We strongly recommend a bladder probe as the one that gives you a continuous core temperature and isn't likely to be lost. Quite a few of our colleagues had experience with oesophageal probes where if it starts to come out during the course of an it stay, if you get into that situation where you're picking up the wrong temperature and you've got a feedback device, then it can start to respond to the wrong temperature. And a lot of these devices are very effective at trying to drive the temperature of its feedback loop towards where you want it. So we've set up to 72 hours of therapy, regardless of which stage of a cardiac arrest journey that you're at and then targeted normothermia throughout that to avoid any temperature over 37.7 with a local choice dependent on the views of senior clinicians, medical and nursing as to whether you want to use 24 hours of hypothermia beforehand. And we're stuck to range 32 to 36 depending on your local views on the ERC guidance and then that chosen temperature needs to be monitored closely and maintained. Again, we come back to it, it needs to be continuous temperature regardless of whether you have a device. So that's the summary parts of the document that I'll show the end, the one page guide relating to temperature control, just reducing that to something as straightforward as we can rewarming. We've talked a little bit more about the need to involve senior clinicians in how that's approached because generally that this is a decision that could be taken during the daytime. You're not going to have to make this decision at three in the morning and targeting 0.25 to 0.5 degrees C per hour after you've had a senior clinical decision that you're going to go for that. And generally, if you're using feedback control devices, they will manage that for you. And if you're not, then you just need to be a little bit cautious about how you approach this. We've said controlled rewarming after any period of hypothermia and continuous temperature monitoring is still recommended passive rewarming. If the patient is hypothermic on arrival at IC is something we all universally agreed on feedback control devices don't always have that as an option. Once you activate them, select target temperature, they will aim for that at their chosen rewarming rate. But things will evolve fairly rapidly in that certainly in the next 1218 months. So this is the summary version of that. These will also come together in the document, I'll show you at the end on neurop prognostication. We said we acknowledge that rebound pyrexia is very common. And those of us with neuro experience think particularly feel that abnormal temperature pyrexia confounds neurop prognostication. Um The data on that is not as good, but it's a fairly commonly held expert view within our group that your G CS will fall. If once you're running past 39 degrees, certainly, then it's a lot harder to work out what's going on with the patient. You need to be fair to them. If you're going to have a period of 72 hours with proper neurop prognostication, then you need to ensure that you're not being unfair to that patient by having them running with a rebound pyrexia, accepting that everybody has different availability of other neurop prognostication tools. If you have NSC, then certainly you should use it but know what you're looking at and for those places that have reliable availability of sseps or eegs then use them in line with what people are comfortable with. And obviously CT and MRI Imaging are a lot more universally available and clearly described in the prognostication sections of the ERC guidelines on outcome measures. Simply said you need to audit this because you need to show that you're achieving best practice that you're aiming for. And you should also be able to demonstrate that you're achieving some better outcomes for your patients in the long term. If you have the option to be able to follow your patients up at 3 to 6 months, it gives you a much better view of what you're doing for your cardiac arrest survivors. In theory, you'd want to know exactly what your data is beforehand. So it relies on having a good clinic set up beforehand. And we would encourage people not to feel that that type of long term follow up is essential to implementing TM using a modified ranking score of less than equal to three or a G OS E of eight, certainly implies better outcomes. They are fairly easily assessed. And if you want to set something up, that's, that's much more practically done without having to create a full clinic service. So we've reduced that down to another two lines and this is essentially the end of that document. So the summary, the recommendations are intended to offer a straightforward way to put together local temperature management guidelines within the limits of the resource that you have or to help you put together a business case to provide resource. If you're looking to financially justify whatever solution you want to implement guidelines tailored to your local need that has involved all your clinical groups as you do put them together is much more likely to have buy in if you want your unit to pass that 3 a.m. test. If you're the consultant on call, then you want something that you know that people are used to implementing and it comes automatically so that someone can be admitted with that cardiac arrest 3 a.m. and you don't have to come in and supervise. And the senior nurses know that all of their junior staff are very used to doing this with a minimum of supervision. You can choose whether you want a period of hypothermia beforehand or not. And again, it's all down to your local interpretation of the evidence. But then auditing compliance and outcomes will give you a route towards demonstrating what you've done. And depending on the financial incentives in your system may well provide a powerful way to demonstrate that you've improved care and justified the money that you asked people to let you spend. This is the document that we've come up with. We haven't circulated this yet. We will eventually, we've put it in for publication with the journal of the Intensive Care Society. We'll be happy to have BD circulate this, but we do need to wait for a publication decision. Created by
