Podcast 126 – TTM Trial Right from Niklas Nielsen’s Mouth

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Comments

  1. Great podcast. No mention though of David Seder’s rebuttal from the neurocritical care conference. I still think there might be something there… in short, treating people with more severe brain injury (by whatever measure you use) with 33. As a cardiologist, my analogy is to ICD. If you had a clinical trial where all people with new heart failure EF 30% were randomized to ICD or no ICD at day zero, it may show no difference. You have to treat the subgroup who’s EF didn’t get better after their ischemia was treated with PCI, and those who get better with meds.

  2. dave barounis says:

    Scott,

    Thanks so much for doing this, it really has helped answer many of my personal questions and address the concerns issued by the by Dr. Polderman.

    Despite this, many clinicians seem very resistant to change their targeted temperature after this trial, despite widespread adoption of hypothermia after 2 small RCTs totaling only 300ish patients. This was an excellent study which most everyone agrees on, there was no signal of difference between the two arms (ALL point estimates of benefit favored the 36 group over the 33 group). The St Emlyn’s blog mentions that the ARR varies from 5.4% in favor of 33, to 8% in favor of 36, which they then use to suggest that you should not be convinced that there is no difference between groups:

    “Are you feeling convinced that there is a difference here? Are you convinced that the results really demonstrate that they are the same? I’m not.”

    While possible it is unlikely that THE SAME TRIAL, if repeated, just by increasing the number of patients would then demonstrate in the next 1,000 randomized patients a detectable difference in favor of 33 degrees when there was no signal of benefit in the first 1,000 patients (this is often why trials are stopped early for futility).

    Also:
    Are you currently waiting to prognosticate all patients (even those with POOR neurologic findings) until 72 hours after rewarming even in the 36 degree temperature group?

    For MAP’s has this paper changed your goals?
    Kilgannon et al. Arterial Blood Pressure and Neurological Outcome After Resuscitation From Cardiac Arrest. Crit Care Med 2014.

    In the ECMO patients that we have resuscitated we have used a temperature of 36, after a few IC hemorrhages at cooler temperatures (32-34) since these patients are also on heparin infusions with ACT goals in the 180 range. I know the Nielsen trial didn’t show this but they also didn’t have patients on the PUMP.

Trackbacks

  1. […] dust still hasn’t settled from the TTM trial. Scott Weingart interviews Niklas Nielsen, the lead author of the trial. […]

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