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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 - PowerPoint PPT Presentation
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CirkulationCooling after cardiac arrest From evidence to clinical practice
Jan Martner SIR
Presenterat vid SFAI-mötet september 2011
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Out-ofhospitalcardiacarrest Hospital
ERICU
CCU/Ward
Survivors
Survivors
In-hospitalcardiac arrest
10 000/year
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Out-ofhospitalcardiacarrest Hospital
ERICU
CCU/Ward
Survivors
Survivors
In-hospitalcardiac arrest
Year 2010
n=1222
SIR 2011
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ICUOut-ofhospitaladmission
In-hospitaladmission
Year 2010
40%60%
SIR 2011
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Out-ofhospitalcardiacarrest Hospital
ERICU
CCU/Ward
404 (33%)Survivors
Survivors
In-hospitalcardiac arrest
Longterm (180 days) Outcome 2010
n=1222
818 (67%)
SIR 2011
6N=275
7
8
9
10
N Engl J Med 2002 346 557N=77
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Results
Improved neurological outcomeMortality: TH 51% vs no-TH 68% (ns.)
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ILCOR recommendation:
Resuscitation 2003 57 231-5
Unconscious adult patients with spontanous circula-tion after out-of-hospital cardiac arrest should becooled to 32-34 oC for 12-24 h when the initialrythm was ventricular fibrillation (VF).
Such cooling may also be beneficial for other rythmsor in-hospital arrest.
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SBU's appraisal of the evidenceThe 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
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2002 2004 2006 2008 2010 2012
Originalpublicationsin N Engl J M
Start of HypothermiaNetworkRegistry
Recommended use by ILCOR
Alert reportFrom SBU
Report from HypothermiaNetworkRegistry published
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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
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2002 2004 2006 2008 2010 2012
Originalpublicationsin N Engl J M
Widespreaduse of TH in Sweden
Start of HypothermiaNetworkRegistry
Recommended use by ILCOR
Alert reportFrom SBU
Report publishedfrom HNR
SIR 10 year anniversery
SIRwas born
2001 2011
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Proportion of ICU patients with cardiac arrest receiving hypothermia treatment 2003-2010:
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34,1% 35,1% 36,9%0%
10%
20%
30%
40%
50%
Proportion of hypothermia treatment according to hospital type
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Proportion of patient recieving hypothermia treatment according to region 2004-2010
35,2%
32,9%
34,7%
37,5%
30,2%
40,6%
0% 10% 20% 30% 40% 50%
Norrland
Uppsala/Örebro
Stockholm/Gotland
Västra Götaland
Sydöstra
Södra
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0
.2
.4
.6
.8
1
And
el m
ed a
ktiv
hyp
oter
mi
0 50 100 150 200 250
Antal hjärtstopp per IVA (juli 2004 - dec 2010)
Proportion of patient recieving hypothermia treatment vs total number of cardiac arrest patients per ICU
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0
.2
.4
.6
.8
1
Pro
porti
on w
ith a
ctiv
e co
olin
g
0 10 20 30 40 50 60
Cardiac arrest out of hospital (cases per ICU 2010)
Active cooling after cardiac arrest
Out-of-hospital 2010 (N=791)
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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 ????
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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 ?
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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)
Comparison of patients with or without activ hypothermia
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Case study II:Active cooling after out-of-hospital cardiac arrest
No active cooling
Active cooling
P < 0.001, Cox
0.00
0.20
0.40
0.60
0.80
1.00
Pro
porti
on a
live
941 280 188 113 71 31No active cooling1162 232 170 118 71 36Active cooling
Number at risk
0 1 2 3 4 5Survival (years)
SIR data from 2005-2010
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Registry studies vs RCT
Data quickly availableReflects ”real life” conditionsCan easily be combined with other registry
data
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2002 2004 2006 2008 2010 2012
Originalpublicationsin N Engl J M
Start of HypothermiaNetworkRegistry
Recommended use by ILCOR
Alert reportFrom SBU
Report from HypothermiaNetworkRegistry published
Start ofTTMtrail
The use ofTH is based onmore solid data ?
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Conclusions 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