Just posted a wee on the game-changing TTM Trial
Managed to get Jon Rittenberger, MD on the line to discuss the implications. Jon wrote the editorial that accompanied the TTM trial and he is an accomplished Resuscitationist and a clinical leader for the U. Pitt post-arrest management team.
Here are Jon's thoughts on what we should do with this trial tomorrow. I add my own opinion at the end. In the next couple of weeks, you'll hear from Stephen Bernard to get his take on the study.
The 2nd article mentioned by Jon is this one:
Prehospital hypothermia in this study and the Bernard trial has not seemed to pan out. Intra-arrest is still in play however.
My Take as of Now
- In the setting of advanced post-arrest care, active temperature management, and protocolized neuro-prognostication; the TTM trial demonstrated no significant outcome difference or trend towards outcome difference when patients were cooled to either 33 or 36C
- Hemodynamics were poorer in the 33C group (This was not mismatching, SOFA-C same on day 1 and much worse in 33C group on day 3; this was a secondary outcome and therefore the study can't demonstrate if this was a significant finding) [Table S2 Supplement]
- Complications were less frequent in the 36C group
- A majority of patients are probably best managed at or near 36C
- In the neurocritical care literature, 35C seems to offer moderation of intracranial pressure
- At Janus General, we will target a temperature range between 35-36C for our V-fib, V-tach, and PEA patients in whom we are pursuing an aggressive treatment path
- Unwitnessed asystolic arrest patients were left out of the HACA, Bernard, and TTM trial. In this group there is little guidance and it may be reasonable to continue cooling to 33C as this group is most likely to have the most severe post-arrest neurologic injury.
Interview with the Lead Author of Trial from the ICN
Matt MacPartlin interviewed Niklas Nielsen, the author of TTM. He is joined by Anders Aneman, one of the local site investigators to discuss this game-changing study.
See this great post from the folks at the Intensive Care Network as well.
The folks at St. Emlyn's offer a more cautious approach.