Podcast 113 – Post-Cardiac Arrest Care in 2013 with Stephen Bernard – Part I

I’ve been waiting for this one for a long time. I got to interview Dr. Stephen Bernard on the topic of post-cardiac arrest care.

Professor Stephen Bernard
Stephen BernardProfessor Stephen Bernard is a senior intensivist at the Alfred Hospital and Director of Intensive Care at Knox Private Hospital in Victoria, Australia. He is also Medical Advisor to Ambulance Victoria. Dr. Bernard was the lead author on one of the original establishing studies for post-arrest temperature management.

 

My discussion with Dr. Bernard was based on a talk he gave at the Australasian College for Emergency Medicine

Photo by Brian Burns

Photo by Brian Burns

Maintain 36 C for 24 Hours

Dr. Bernard and the Alfred Hospital in Australia are moving to the protocol outlined in the TTM trial

Is there anyone who still deserves to be cooled to 33 C?

Dr. Bernard feels patients that get intra-arrest cooling may still benefit until we have further trial results.

Neuro-Prognosticate as per the protocol in the Nielsen trial

Chris Nickson summarized the Neuro-Prognostication Protocol wonderfully

Time Zero Prognostication

It is tough. Unwitnessed asystole is probably one situation in which you can choose a palliative route if the situation otherwise supports it.

Pt should be taken to a 24/7 cardiac interventional center

This doesn’t necessarily mean the patient needs to go to the lab immediately, they just need to be able to go when needed

Lower FiO2

Maintain an SpO2/SaO2 between 90-95%

Normal PaCO2

No hypocapnea, Perhaps slight hypercapnea

Tune in Next Week for Part II of the Interview

More on the TTM Trial

The Thoughts of Others

More from Steve can be found at the EDECMO Podcast Site

Now, on to the Podcast…

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Comments

  1. Fantastic to have Steve Bernard share his wisdom on the EMCrit podcast.
    He shows himself to be a true scholar and scientist, the way he has assimilated the findings of the TTM trial despite his long and ongoing interest in therapeutic hypothermia.
    Steve, I salute you!
    Chris

  2. “Induced hypothermia does not have a role in any patient outside the context of a high-quality RCT.”

    Woo, strong statement to digest.

    • Garreth Debiegun says:

      And I have to respectfully disagree. In the TTM study they calculated a 90% power to find a difference of 20% in mortality. This was their primary outcome. I’m not sure why. The two original HACA studies (Benard & Holtzer) both found less than 20% differences in mortality. So even before the TTM study enrolls a single patient I expect them to find a null hypothesis.
      In TTM Nielsen did have secondary outcomes to look at intact Neurologic function. This is what we really care about and I’m not sure why it wasn’t the primary outcome. Bernard & Holtzer both intelligently made it their primary outcome. If this outcome did have a 20% difference then Nielsen still might convince me of 36 degrees. But Bernard had only 77 patients and Holtzer who had 275 patients found only a 16% functional difference. So still I expect that Nielsen would find no difference.
      I really wish Nielsen had powered the study to find a 16% difference in intact neurological function. But he didn’t so I can’t change my practice based on TTM. Still with 950 patients he more than doubled the total number of HACA patients in the world database and opened up a new discussion. My hats off to Nielsen for a strong piece of work that informs a new possible thinking in post arrest care.

  3. Bart Massaer, emergency physician, Belgium says:

    Why not titrate vaopressors to “Mean Arterial Pressure”, more reflecting organ perfusion compared tot systolic blood pressure?

Trackbacks

  1. […] to vote for this as Ripper of the Week as I have too much conflict of interest… Regardless, Scott Weingart talking to Stephen Bernard from The Alfred about post-arrest care is a MUST listen! […]

  2. […] Emcrit.org – Scott’s wee on TTM and Interview with Dr. Stephen Bernard  […]

  3. […] care: EMCrit interview with Stephen Bernard part 1 and  part […]

  4. […] second is Scott Weingarts interview with Stephen Bernard author of “Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest […]

  5. […] Weingart also has a great post and podcast on this as […]

  6. […] interview with Steve on Post-Arrest care at the Emcrit.org […]

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