Transcript Video Which Patients Should be Measured, How and When?Assoc. Prof. Katia Donadello < Back to Boundaries of Temperature Session 3: Utility Which Patients Should be Measured, How and When? Presented by Associate Professor Katia Donadello Good morning everybody. I hope you had a wonderful dinner yesterday evening and a refreshing morning run to start with the first session this morning. And as the first speaker I may announce. Professor Donna Dello. She's associate professor of anesthesia in intensive care in Verona and she is a member of the T. T. M. Task force of the european Society of intensive care Medicine. And the title of her presentation is which patients should be measured, how and when. Good morning everybody. So has thank you for the introduction and has it has been introduced. I've been asked to depict you which patients should be measured how and when. And I hope that I will be able to highlight you that my point of view might be different from the ones that have been depicted yesterday. So we all know that in acute brain injured patient and in cardiac arrest survivors, the brain injury is just one of the four items that depict the post cardiac arrest syndrome and within the acute brain injury that characterized the cardiac arrest survivors. The ischemia re perfusion phenomenon plays a major role. And during the past 20 years we have heard read and studied that temperature. He is among the different therapies that have been tested and studied in order to improve patient outcomes, mostly neurological outcomes. As we heard yesterday, brain he is characterized by temperature or metastases and despite the fact that the temperature fluctuations, fluctuations, sorry, our physiological those alterations in the temperature might be the effect and the cause of pathological events. We know that this year the E. R. C. And E. S. I. C. M. Have published the updated guidelines on how temperature should be managed in cardiac arrest survivors. And we are recommended to monitor temperature continuously and to prevent fever. But the problem is that we have spent more than 10 years treating cardiac arrest survivors with hypothermia. And when we talk or think about hypothermia we might distinguish between what is controlled what we used to use as a as a therapy and what is uncontrolled. So despite the fact that now during the past two years so we've been talking a lot more about normal therm. Eah uncontrolled, spontaneous, accidentally driven hypothermia might be pathological and dangerous. So if we think about cool temperature temperature might be not too cold. So with the beneficial role as was summarized in 2020 because it is able to reduce the cerebral metabolism, reduce exit to toxicity and reduce the inflammation and the apathetic processes. And it is known that temperature is able to influence indeed many key destructive mechanism that follows brain injury. But temperature may also go too low. And It is roughly 60 years that we know that low temperatures might impact in a bad manner. The way that perfusion microvascular perfusion may be driven that low temperatures might induce metabolic and metabolic disturbances and alter bleeding cascade and might alter immune modulation. Okay and if we go on the microvascular uh aspect it has been shown that cool temperature might alter micro perfusion both within the body. And we've seen that it can be altered also within the brain. So this is a paper that we have just submitted were healthy pig were treated with low temperature and micro vascular cerebral microvascular perfusion and cerebral metabolism were significantly impacted during the cooling process. And we know that cooling might alter aerodynamic inducing arrhythmias. So we know that when temperature goes too low this might have a deleterious effect within the whole body. So I might say that any episode of uncontrolled hypothermia might affect patients clinical evolution. So if it is too cold, this might be prevent, but temperature might rise and might be too hot. And we know that hypothermia might be deleterious because fever might all tear BBB permeability and might decrease Sezer threshold. And we know, you know that fever has an impact on outcome on all accurate brain injured patients and that not only neurological outcome might be impacted, but also mortality might be increased by post hypothermic fever. And if we have a look at this um trial, this was it was published in 2017. And the fact of having just an episode of more than an episode within the 1st 24 and within the 1st 36 hours of temperature higher than 38° was influencing significantly outcome. And when evaluating if there was a difference among patients are treated at with my departure mia with normal term at 36 degrees. The authors realized and underlined that it was much more difficult to stick to 36 it was characterized by a higher risk of having fever And if we have a look at trying to keep the patient normal thermic after therapeutic hypothermia period. The fact of having a controlled normal hermia after hypothermia was related was associated with an improved outcome compared of having an uncontrolled and uncontrolled period of time after the hypothermic period. So any episode of uncontrolled fever may affect patients clinical evolution. So on one hand the extreme low and the extreme high temperatures might be deleterious. So we might just keep the temperature at the just right level. And when we think about temperature unfortunately and I might say unfortunately during the past years we have shifted from talking about therapeutic hypothermia to target temperature management to temperature management. But temperature we might think about temperature of something that comes above all the different treatments that we apply to our patients. I mean the cardiac arrest survivors are some of our critical care patients and we improved the management of our patients Along the past 20 years. So it is one of the treatment that we apply and we might say it is the hat of the treatment that we might apply. But when we evaluate something we need to measure what we are doing in order to analyze the effect of what we are doing and to improve based on the results of the analysis that we are making. And we have seen that after the T. T. M. Trial results, things have changed all over the world, attitudes and manner of treating cardiac arrest survivors have changed shifting from a mild hypothermia approach to a normal hermia approach. But unfortunately the fact of changing the target temperature has brought to a even if in the US not significantly related to a reduction of temperature management and to an increase of mortality. And if we go and see what happened in Australia and New Zealand the shifting from 33 to 36° in temperature management was related was associated with an increase in mortality. But what is striking is not just the fact that there is this a significant relationship or there is not a significant relationship is the fact that changing the target temperature was associated with the reduction in compliance to target temperature with a higher rate of fever in the treated patients and with the trend towards a worst patient outcome. And indeed this is um an interview that was delivered in florida. It is just a letter to the editor as you can see. But the replies to the questions that were asked to the physician. So if they were applying T. T. M. And how they were selecting patients and why they were not selecting patients. As you can see there are reasons that are pushed forwards that are related to the literature and there are not related to the literature. I mean like the fact of not having resources, enough resources are not being sure of the results that might be shown up by the method applied. And this might call us to try to find a uniform way and homogeneous way of treating cardiac arrest survivors. I mean, having a sort of uniform, uniform attitude way of managing all of them. Because the fact of um implementing cardiac arrest survivor treatment might not abandoned, might not go far away from temperature management because as we have heard yesterday and as we might here today, temperature is a corner storm a part of cardiac arrest survivor patients. And even if we think about, we think about T. T. M. To trial the normal for me, a group was submitted to an active management of temperature and more than 50% of patients. So it was not the fact that choosing a normal therm mia was going far away from an active management of temperature in those patients. But if we go and see how the pivotal trials on T. T. M. Were conducted, the kind of patients that were selected that might have driven some of the conclusions conclusions that have been driven in the past few years are not the patients that most of us treat. I mean, if this is what we have in europe and I put what are the percentages in Italy And more than 70% of patients in the pivotal trials had a shock herbal rhythm at as a cause of cardiac arrest. We're not reading those kinds of patients. So I might not think that just sticking to the kind of rhythm that was registered at the moment of cardiac arrest is sufficient to decide what to do with the patient. So two years ago we published the sort of summary on the uncertainties that are still present about the way of using the temperature management after cardiac arrest. And I might say the temperature has to be conceived as a drug. So when you prescribe antibiotics, you decide that there is an indication and you choose an appropriate and adequate way of administering that drug. And I believe that temperature might be conceived at the same level. So if we think about what Fabio Taccone published two years ago. So the fact of performing the temperature management of high quality the temperature management does not mean just choosing a temple and choosing a method, we should perform a sort of high quality temperature management. That means that if we try to stick far away from hypothermia and hypothermia, if we might believe that hypothermia might not be the best choice for our patients, we need to stick to a normal thermic approach. And in this case, when you choose the normal thermic approach, you can delayed, you can forget the cooling and the post cooling face. But you need to stick to the fact that your temperature must maintain A physiological temperature for the worst period of time within the icu admission. So has the guideline says at least the 1st 72 hours in all comatose patients after cardiac arrest. And if we go and see if the quality of temperature management was I or not. Within the big trials that have been performed when we the 48 the T. T. M. 48 trial showed that more than 80% of patients were not treated with the high quality T. T. M. And more than 20% of them were treated with a low quality T. T. M. What does this mean? This means that means that we need to have an S. O. P. We need to have a standard of care. A practical and precise approach to this kind of patient. So this means that we need to measure the temperature at the right place at the right time in the right manner. So it means that we need to stick to the core. So blood is of a jail or blood er if feasible. And it has to be a continuous and it has to start from the beginning of the ICU admission because every minute every hour might be the one where the temperature fluctuates. We know that as methods are taken into account we need to stick to an approach where the core measurement and the core um temperature control. Temperature control. Yes are measured and managed that there is a sort of superiority of invasive compared to non invasive measures of of uh temperature management. And we need to have a feedback. There is not a superiority in neurological outcome and in general outcome of patients between the surface and the endovascular. But we know that we need to have a feedback. We need to we need the machine to be able to account for the patient temperature and to control it minute by minute enabling us to stick far away from variability. We need to have a protocol and nearly 50% of patients of cardiac arrest survivors are not treated with the protocol are not treated with a precise and adequate S. O. P. And most barriers to the application of temperature management are on one hand, knowledge deficiency but also the fact that the resources and the reinforcement are not clearly and um crystal clear established. We might have a simple protocol but I believe that simple protocol might be difficult to be implement and to be followed mostly by nurses and healthcare professional. I believe that we need to apply precise protocols where all patients vary, May be recorded and followed so as to be able to take into account all different vary abilities that patients experience during the 1st 72 hours. So taking into account all the side effects that temperature might dream. So we need to keep the temperature just right. So we have seen that we there is not uh it is not pivotal to decide right now just now. If we might stick to 32, 33, 35 or 36. But we might stay with physiology because physiology is what makes the brain and the body works better. And despite the fact that we still have research priorities, we still have holes and pitfalls that are not completely highlight lee and made clear, I believe that all cardiac arrest survivors should be monitored and all cardiac arrest survivors should be should benefit of a temperature control management. That not mean that doesn't mean that patients should be cooled or should be um made warm. It means that all patients should be kept far away from pathological fluctuations. So body temperature regulation is tightly controlled in a healthy individual but is often altered after an A B, A. B. I. And A B. I. Patients often experience fever but not only fever, also hypothermia might be deleterious. And despite guidelines, temperature management is still questions on its effectiveness and its implementation. But I believe that temperature management needs to be conceived and applied has a drug. So we need a scheme, a protocol with the wrote a device we need to establish those and intervals so the duration the way to um distribute the temperature and we need to accurate and adequate monitoring temperature. Thank you Created by
