Prof. Jerry Nolan - a giant of resuscitation - discusses why we can't replicate the trial outcomes in cooling post-cardiac arrest.... #SOA21 A thread ๐งต๐
Jerry Nolan presenting! We know for sure that hypothermia BEFORE something like cardiac surgery is protective. As well as pre-cooling prior to cardiac arrest! #SOA21
Many animal studies. Mimic the clinical conditions of cardiac arrest. #SOA21 The timings here are important - mean no (asystole) /low-flow (CPR) times. Hypothermia induction times immediate OR delayed up to 60mins. Hypothermia improved neuro outcome and reduced mortality by 67%.
How do we move on from these studies? These ones (below) were unblinded, which was quite a problem. #SOA21
Is fever harmful after cardiac arrest? Maybe. No huge evidence base for this. #SOA21
One of few RCT's recently to show benefit for hypothermia... just one patient would have changed this study though... (Frag index, if you believe in it) #SOA21
And so this all led on to TTM2... not significantly different. #SOA21 ... leading to a barrage of discussion points from around the world.... saying TTM2 etc do not represent "our sorts of" cardiac arrest patients.
Bystander CPR, Time to cooling, ICU patients(not register patients), non-standardised post-arrest care - SO MANY variables.... #SOA21
Is the key to understanding why we can't replicate, the time to target temp? FIVE HOURS??? in most studies. ?Too long? #SOA21
Giving cold IV fluid intra-arrest though may be harmful.... so... #SOA21
Intranasal cooling!!! #SOA21 ~700 patients. Could data show trend towards being quicker in transnasal group? Faster temp reduction?
So: this is a bioplausible phenomenon, but this hasn't been born out in clinical trials (yet?). No high-certainty evidence that fever control results in better outcomes.... that will be looked at closer in TTM3 (which has just got funding...) #SOA21
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What were the most impactful non-COVID papers over the past 2 years? Let's delve in and take a look. #SOA21
Finally an opportunity to not talk about COVID! #SOA21
TOMAHAWK - immediate vs delayed/selective angio. 3 years to conduct the trial in 31 ICUs. 554 patients. 'Worse' survival in immediate angiograph? Not SS, but close... #SOA21
We've looked at bats for a long time.... #SOA21 They have strong interferon responses, but not strong inflammation....
So what happens instead? #SOA21 They will tolerate high levels of viraemia with little symptoms. Bats are old... 65million years ago - they appeared at the end of the dinosaurs! They are far longer lived that other mammals. Senescence is late - more towards end of life.
Organophosphate poisoning, toxicology, dengue, snake bites and malaria.... sure what could go wrong? #SOA21@ICS_updates Drs. Chacko, Yacoub, Bhaumik and Dondorp tell us more.... ๐งต๐๐
Biomarker guided abx treatments in sepsis. We catch up with Drs/Profs: Paul Dark, Stacy Todd, Enitan Carrol, Jonathan Sandoe and Matthew Stevenson on this large area of research @ICS_updates#SOA21
So, do biomarkers have any utility in guiding abx use in sepsis? We can measure, usually, these ones fairly easily: #SOA21
In around 2014, commissioned review in PCT. Seemed to suggest a shorter duration in abx use when PCT used.... tenuous data though. #SOA21 Low quality. Little evidence from UK... how does this fit into NHS practice in the realms of stewardship?
There's been a lot that's gone on over the past few years that's exposed the well known 'darker' side of social media. Traditional paradigms of knowledge dissemination have changed (if not disappeared). Much higher tech-savy population. #SOA21
This has democratised the discussion space to an extent. It allows for *anybody* (lit. anybody) to get involved. #SOA21
Is COVID-19 hyperinflammation, or a cytokine storm in a teacup? @DrPujaMehta1 's fab talk from #SOA21 today!
Main Q = "Hyperinflation contributing to worse outcomes for some patients with COVID-19" - clinical similarities to sHLH seen. Viruses are the most common trigger of sHLH. Early reports from China suggested cytokine profile was similar to sHLH in terms of COVID severity. #SOA21
We now know some things work and some things don't.... in certain populations. #SOA21