Transcript Video When to Stick and When to TwistDr. Tommaso Pellis < Back to Boundaries of Temperature Session 7: Benefits When to Stick and When to Twist Presented by Dr. Tommaso Pellis So actually come to the last speech dr Tomaso Palace. He is uh the head of anesthesiology and intensive care medicine at Hacienda Hospital era santa Maria degli Angeli and his co author of the T. T. M. One trial. And he followed thereafter with papers very important papers how to implement best practice and make it workable for every intensive ist. You're welcome. So thank you. It's it's an honor to be here and to close this very nice conference. It's also a very difficult talk to give after two giants of the science of cardiac arrest and resuscitation. But I also have a very important opportunity which is to pinpoint a few take home messages besides the fact that we don't talk anymore about T. T. M. But temperature control and I think we all know this by now. Thanks willie. Um And I'll promise you, I'll show you at least a couple of new slides but before showing you some new slides, I'll walk you rapidly through the take home message. Is that the milk or the guidelines have given us and I don't want to bore you really. So I'll be very very fast, actively prevent fever. Remember about sub populations or remember that there are centers that still run 33C programs of temperature control um Use a surface or endovascular with feedback uh ongoing feedback system and prevent fever for at least 72 hours. But then if you go through the ill course statements in it, there is a a part which to me is where the meat is and it's where these authors um the scientists provide you with the justification and the evidence to decision framework. So they highlight here why they picked those conclusions and this is very important to remember. So first of all all members of the task force agreed to continue to recommend active temperature control. So this you cannot you cannot avoid active temperature control basically. And why is that? Because they're all concern that poor implementation would lead to potential harm of our patients. So this is a key important message to take home. And there is still discussion about the definitions of normal therm E A. And fever. And you can see here some numbers which come from the large cohort. Probably we have discussed this throughout the last two days in detail, But to me this means that 36C and 37.5 are in the same group of normal ther mia. Okay. And as a matter of fact they did a sensitivity analysis and they saw that putting 36 Celsius within the fever prevention group doesn't change the maths and the results in terms of outcome. And so this led eventually to the guidelines and we've seen this table or um cartoon many times. And now let's get to my emotional part of the talk and probably to the new slides. Um so how did all this change my practice. Um actually it didn't at least not so far and I have a couple of reasons why and they are linked to the way to the to the place I work to how we work and to the problems and the issue we have with implementation and uh that we have faced in the current years in the last two years. So first of all, let me say there is still controversy on the topic and you've heard that you've heard that throughout the day um until the dust has settled. I'm not in a hurry. We're running a temperature control program at 36 Celsius, which again falls within the definitions of normal ther mia. So we don't we're not in a hurry, we're not urged to make any changes and that's my personal take on that. And as an example of the fact that there is still some the dust has not settled. There is still some controversy. This is a a free statement that was given was submitted to Ilker while the statements of Ilker, we're open for discussions and as you can see they come from Willie and Ben that we're here today and just talked into until a few minutes ago and and I thought this would be a new slide but it's not actually um this was what Willy submitted with Ben and he just showed us um meaning that meta analysis run by different groups show some different interpretations And speaking about men analysis, this is an individual patient and analysis that has just been published a few days or two weeks ago. Um this comes from the an individual patient analysis of the TTM- one and TM- two studies. And within this meta analysis there is a very nice forest plot that really loves a lot and it's so there's so many subgroups that you can't actually read it. Probably. So I have enlarged it for you and still you cannot read it properly. But what I wanted to point out is that if you enlarge the last part, then there is a an interesting finding and this is still about controversy in the field of temperature control. And you can see here that there if we look at bystander cpr No. Bystander Cpr points in the direction of favoring hypothermia temperature control at hypothermia hypothermia temperature control. While bystander cpr looks just the rest of like just of the rest of the subgroups touching the middle line. So you might argue this is a random finding and it could well be because if you keep splitting the data into subgroups, then eventually one out of 20 would be a finding which is out of chance, pure chance, pure random effect. Nevertheless, this is still here and I guess there will be discussion on this coming. So let's get to my personal uh take and what will I change and why we changes Have we started doing since the publication of the T T. M. Two and the updating of the guidelines. So we really didn't change much as I said, we just looked at minor protocol features based on the protocol running the T. T. M. Two but we didn't really didn't touch temperature management. And that's because we ran a protocol which is well accepted. Well well deployed every time we needed which is based on the T. T. M. One. We were part of the T. T. M. One and strictly followed its well known and it's based on a temperature control of 36. In the two last two years we went through the pandemic crisis. We had continuous changes. We reshape words I. C. U. S. O. R. S. And as a matter of fact I don't know your personal situation. We're starting on the fifth wave uh and we are reshaping our our internal words and we are expanding our beds for covid patients in the ICU once again right now. So um that's one of the reasons why I'm not making any hard change in this very moment. And most of all I don't know your personal situation but we are going through a very deep nursing crisis. We're lacking of nurses, nurses are moving out of the uh tough words like the E. D. Like the I. C. U. And so we don't have a real luxury on making subtle changes which require a lot of effort and which would uh which would stress acceptance of new things with very little uh patient centered outcomes. Let's put it that way. So um consider carefully the aftermath of any change. For example. Um I can I can tell you that in my unit at least whenever we don't apply A. T. T. M. Or temperature control protocol, then we appreciate a major disruption in the order sets that usually come along with temperature control. So that's for example um radiology labs, drugs, sedation, pro protocols and so on. Uh So we basically end up with a loss of momentum in high quality post resuscitation care and we're not ready for a multi model prognostication when it's time to do that. So um these are other examples of uh consequences. How would you deal with neuro checks? Would you keep sedation? Would you start sedation holidays basically? Would this become a physician driven approach? Individual approach or will be or will it be still standardized? So think carefully of what the consequences of a change might be. And again I share the same concern of the task force. I'm very concerned about the low the loss of focus on fever and managing temperature. Um can be hard, can actually be hard to swallow if you're not a very committed and very a center which runs high numbers high volume cardiac arrest center, especially if you are chasing temperature instead of managing if you're not on top of it. But you're running after it? And you're probably familiar with the slide of the T. T. M. Two by now. This is definitely not a new slide, what I haven't heard and or at least I haven't heard being stressed over and over again. And I think this is another important take home message to take away with you in in a few minutes. Is that remember that in the fever prevention group of the T. T. M. Two, almost half of the patients ended up with a temperature control feedback device because they were over shooting the safety barrier. Okay, so 50% of the patients required a safety uh a parachute to be opened and the feedback control to be device to be deployed. As a matter of fact, many centers were so concerned that for example, we're applying or introducing a temperature management catheter beforehand, just in case. So this depicts in my mind a clinical scenario Which is that of a patient that is exposed to what we currently consider in the guidelines and between experts a potential clinical harm and this is potentially happening in 50% of our cases within the next 12-24 hours. So this to mean means taking a preventive action basically. Or if not, I would expect that the system would be very strictly enforcing, monitoring triggers, thresholds order sets something like in other clinical scenarios avoiding an overcorrection in chronically and severe hyponatremia nutri mia, which is another one of the pictures that came to my mind very similar to this high risk situation but squeezing a little bit my brain and I think this is a new picture in a common sense scenario for me in real life in everyday life, this sounds like a difficult crossroad, a hazardous crossroad and my life is somehow uh somehow different from yours maybe uh in in in that that I have four Children and this 44 little Children are running everywhere and they're very hard to handle. And as a matter of fact this is one of the few pictures we have altogether. And to take this picture, you see, I'm grasping hard on my, on my son and I'm Grabbing the other one with the arm and that's because they tend to go in every direction. Now if we are approaching this crossroad and if there is like a 50%% chance of getting into a danger zone, I would rather take them by the hand and not wait for them to get close to danger before taking action. So this is somehow my take and um for one more thing to add on top of this is that this crossroad can be either in japan or in Germany and that's fine, probably my kids would not be that endangered, but I'm not working neither in japan or in Germany, I'm working in italy and if you approach this kind of crossroad in italy on average, I recommend you pay a lot of attention, okay. Um but now going back a little bit closer to science than to personal and emotional transfer. Um Keep in mind that passive antibiotic therapy might not be enough to get you where you want or to to increase the safety buffer that you're looking for um in in post resuscitation care. Another thing that I want to point out as a take home message and I'm glad I have a few neurons that work in synergy with with burns is the chain of survival. Don't forget that this chain of survival has been shaped the way it is by replacing advanced life support with post resuscitation care. Thanks to temperature control to temperature management. And this has given momentum to a whole new field which is post resuscitation care which was not there at all. So don't throw away the baby with the water altogether. Please don't lose momentum on high quality post resuscitation care. Remember that And that for us um is uh is extremely important. Again I work in a situation where the nurse crisis is becoming extremely extremely difficult to handle. And so the nurse ratio patient is so bad that at times we have one nurse for three patients. So if I have a nurse set by the patient as a watchdog, I can probably handle immediately a temperature which is rising. But if I have a nurse which is running up and down and looking after covid and non covid patients I have to rely on technology over and over and over as much as I can. Okay and I won't I won't spend a lot of time on this because we've heard this over and over. Right. This is the risks that are underlying um underlying implementation in real life implementation is in real life is different from motivated, well trained, extremely stressed academic centers with a lot of resources, a lot of doctors, a lot of people that are keen and discussing the issue over and over and over. Okay, so this is this is a story which started back in 2017. So now it's five years and this is Stephan Bernard, he started realizing with bray that things were not going exactly as they were going in the T. T. M. One trial. And as much as I was part of the T. T. M. Trial one trial, I am uh I'm aware that implementation has been a big problem. The results don't match real life. I'll keep this one in the interest of time, fever has been increasing and we've seen this over and over with fever increasing mortality instead of keep decreasing, has changed direction and is rising up another take home message. And this is another meta analysis of or a systematic review of real life implementation which is failing to demonstrate the same things that we see in big randomized trials with motivated centers selected motivated centers. Okay, so my conclusion and I believe almost the conclusion of the conference is that abandoning temperature management or temperature control is not an option Don't abandon your patients into danger zone without a nice clear plan, actively prevent fever by targeting a temperature less than 37.5 and do that in those who remain comatose for at least 72 hours. And if you change, if you make a change, make sure you're able to do that for real, audit the process of care and the outcome. Thanks. Created by
