By John Weeks
There has been an explosion of conversation about Targeted Temperature Management (TTM) in post-arrest patients following the publication of the TTM trial by Nielson et al in the NEJM recently.
Full article - Engl J Med 2013; 369:2197-2206 December 5, 2013
There has been loads of commentary and debate and I won't try to re-invent the wheel here.
Obviously I suggest you read the paper, listen to the podcasts and decide on your own opinion. However, I would probably summarise what I learnt as:
- HypERthermia after a cardiac arrest is probably bad (not contained in this paper but useful background knowledge)
- Controlling the temperature to 36°C may be the same as cooling the patient to 33°C, but we don't know that. We do know that there isn't a large difference.
- Studies to prove similarity between two interventions have to be massive (studies to show no difference can be smaller - MATHS fans)
- Cooling is an intervention and like any other thing we give (e.g. drugs) there is probably a dose-response relationship
- Neuroprognostication is difficult in the context of hypothermia and difficult post-cardiac arrest, and the two combined make things exceptionally tricky.
It may well be that different patients need different temperatures (for example patients with a long down-time and asystole might require longer at a lower temperature) - but clearly more studies are needed before this becomes practice.
Some links:
There's some useful background info on post-arrest hypothermia from Lewis Macken from SMACC 2013. This talk pre-dates the release of this trial but has some really interesting points, esp how small the numbers are in existing RCTs
A very readable summary from The Intensive Care Network
Interview with Nielson, the primary author of the study
St. Emlyn's info on the stats behind the trial
There has been an explosion of conversation about Targeted Temperature Management (TTM) in post-arrest patients following the publication of the TTM trial by Nielson et al in the NEJM recently.
Full article - Engl J Med 2013; 369:2197-2206 December 5, 2013
There has been loads of commentary and debate and I won't try to re-invent the wheel here.
Obviously I suggest you read the paper, listen to the podcasts and decide on your own opinion. However, I would probably summarise what I learnt as:
- HypERthermia after a cardiac arrest is probably bad (not contained in this paper but useful background knowledge)
- Controlling the temperature to 36°C may be the same as cooling the patient to 33°C, but we don't know that. We do know that there isn't a large difference.
- Studies to prove similarity between two interventions have to be massive (studies to show no difference can be smaller - MATHS fans)
- Cooling is an intervention and like any other thing we give (e.g. drugs) there is probably a dose-response relationship
- Neuroprognostication is difficult in the context of hypothermia and difficult post-cardiac arrest, and the two combined make things exceptionally tricky.
It may well be that different patients need different temperatures (for example patients with a long down-time and asystole might require longer at a lower temperature) - but clearly more studies are needed before this becomes practice.
Some links:
There's some useful background info on post-arrest hypothermia from Lewis Macken from SMACC 2013. This talk pre-dates the release of this trial but has some really interesting points, esp how small the numbers are in existing RCTs
A very readable summary from The Intensive Care Network
Interview with Nielson, the primary author of the study
St. Emlyn's info on the stats behind the trial
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