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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

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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