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Targeted Temperature Management after out of hospital cardiac arrest

9/2/2014

2 Comments

 
Picture
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

2 Comments
A. Lu
12/3/2014 07:20:28 am

You might be interested in reading this - http://lifeinthefastlane.com/need-talk-ttm/

Reply
John Weeks
13/3/2014 08:30:53 am

Thanks April, interesting stuff. Also interesting how it has/may have been misinterpreted. Similarly there was a podcast a couple of weeks back on The Intensive Care Network by Aneman, who was one of the lead authors of the TTM study.

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