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Cooling after cardiac arrest From evidence to clinical practice. Presenterat vid SFAI-mötet september 2011. Jan Martner SIR. In-hospital cardiac arrest. Out-of hospital cardiac arrest. Hospital ER. ICU. Survivors. 10 000/year. CCU/Ward. Survivors. Year 2010. In-hospital

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Cooling after cardiac arrest from evidence to clinical practice

Cooling after cardiac arrest

From evidence to clinical practice

Presenterat vid SFAI-mötet september 2011

Jan Martner

SIR


Cooling after cardiac arrest from evidence to clinical practice

In-hospital

cardiac arrest

Out-of

hospital

cardiac

arrest

Hospital

ER

ICU

Survivors

10 000/year

CCU/Ward

Survivors


Cooling after cardiac arrest from evidence to clinical practice

Year 2010

In-hospital

cardiac arrest

Out-of

hospital

cardiac

arrest

Survivors

Hospital

ER

ICU

n=1222

CCU/Ward

Survivors

SIR 2011


Cooling after cardiac arrest from evidence to clinical practice

Year 2010

In-hospital

admission

40%

60%

ICU

Out-of

hospital

admission

SIR 2011


Cooling after cardiac arrest from evidence to clinical practice

Longterm (180 days)

Outcome 2010

In-hospital

cardiac arrest

818 (67%)

Out-of

hospital

cardiac

arrest

Hospital

ER

ICU

404 (33%)

Survivors

n=1222

CCU/Ward

Survivors

SIR 2011




Results
Results

  • Improved neurological outcome

  • Mortality: TH 51% vs no-TH 68% (ns.)


Cooling after cardiac arrest from evidence to clinical practice

ILCOR recommendation:

Unconscious adult patients with spontanous circula-

tion after out-of-hospital cardiac arrest should be

cooled to 32-34 oC for 12-24 h when the initial

rythm was ventricular fibrillation (VF).

Such cooling may also be beneficial for other rythms

or in-hospital arrest.

Resuscitation 2003 57 231-5


Cooling after cardiac arrest from evidence to clinical practice

SBU's appraisal of the evidence

The scientific evidence is insufficient* to show that treatment with induced hypothermia after resuscitation from cardiac arrest improves survival or lowers the risk for permanent functional impairment. Although the scientific evidence is too weak to support reliable conclusions, the method appears to be promising and potentially may be of clinical importance. However, it is essential to continue testing this method in Sweden under scientifically acceptable conditions so that its benefits, risks, and cost effectiveness can be assessed. Until adequate scientific evidence is available, therapeutic hypothermia should be used only within the framework of well-designed, prospective, and controlled trials.

Alert report from SBU 2006


Cooling after cardiac arrest from evidence to clinical practice

Original

publications

in N Engl J M

Alert report

From SBU

Start of Hypothermia

Network

Registry

Report from Hypothermia

Network

Registry published

2002 2004 2006 2008 2010 2012

Recommended use

by ILCOR


Results1
Results

  • From 2004 until 2008 986 patients were reported the Hypothermia Network

  • 50 % of the patients had a longterm survival

  • > 90 % had good neurological function


Cooling after cardiac arrest from evidence to clinical practice

Original

publications

in N Engl J M

Alert report

From SBU

Widespread

use of TH

in Sweden

Start of Hypothermia

Network

Registry

Report published

from HNR

2011

2001

2002 2004 2006 2008 2010 2012

SIR

was born

SIR 10 year

anniversery

Recommended use

by ILCOR





Cooling after cardiac arrest from evidence to clinical practice

Proportion of patient recieving hypothermia treatment vs total number of cardiac arrest patients per ICU


Active cooling after cardiac arrest
Active cooling after cardiac arrest total number of cardiac arrest patients per ICU

Out-of-hospital 2010 (N=791)


Why was the introduction of th after cardiac arrest so rapid
Why was the introduction of TH after cardiac arrest so rapid ?

  • Contrary to drugs no official approval was required

  • No substantial extra costs except increased LOS in the ICU

  • An effective tool to improve outcome after cardiac arrest was much desired

  • ILCOR recommended TH

  • Group pressure ??

  • Perhaps intensivists are more bold and impatient regarding introduction of new methods than other doctors ????


Can the results from the rcts
Can the results from the RCTs ?

  • with a very high degree of patient selection

  • with strict protocols

  • and performed in dedicated ICUs

    be replicatet in a widespread ”real life” use with broader inclusion criteria ?


Cooling after cardiac arrest from evidence to clinical practice

Tabell 1 - Jämförelse av patienter med och utan aktiv hypotermi

Comparison of patients with or without activ hypothermia

Activ hypothermia

No aktiv hypothermia

P-value

Number of patients

1398 (36.1 %)

2520 (64.3 %)

Age , mean (SD)

64.1 (15.6) år

67.2 (16.8) år

<0.001 (t-test)

Gender (Male/Female)

70.4 / 29.6 %

62.8 / 37.2 %

<0.001 (Chi2-test)

Risk of death (Apache), mean (SD).

74.5 (16.7) %

N=762

71.3 (22.9) %

N=1294

<0.001 (t-test)

LOS ICU, median (IQR)

88 (55-141) tim

30 (9-74) tim

<0.001 (t-test)

Surviving patients 30 days after ICU admission

41.3 %

30.7 %

<0.001 (Chi2-test)

a bedömt enligt APACHE-systemet (8)


Case study ii active cooling after out of hospital cardiac arrest
Case study II: hypotermiActive cooling after out-of-hospital cardiac arrest

SIR data from 2005-2010


Registry studies vs rct
Registry studies vs RCT hypotermi

  • Data quickly available

  • Reflects ”real life” conditions

  • Can easily be combined with other registry data


Cooling after cardiac arrest from evidence to clinical practice

Original hypotermi

publications

in N Engl J M

Start of

TTM

trail

Alert report

From SBU

Start of Hypothermia

Network

Registry

Report from Hypothermia

Network

Registry published

The use of

TH is based on

more solid data ?

2002 2004 2006 2008 2010 2012

Recommended use

by ILCOR


Conclusions
Conclusions hypotermi

  • TH was rapidly introduced in Swedish ICUs in spite of effects not being fully scientifically proven

  • There are no differences between different types of hospitals regarding introduction and use of TH although there are large differences between individual ICUs

  • There are minor regional differences regarding the use of TH

  • ICUs admitting many patients after cardiac arrest show more conformity in the use of TH

  • A national quality registry with good cover is a valuable tool to monitor introduction of new therapeutic strategies

  • Survival (30 days) ”in real life” was higher after TH perhaps indicating a positive effect of TH