Cooling after cardiac arrest From evidence to clinical practice

1. Cooling after cardiac arrest From evidence to clinical practice Presenterat vid SFAI-mötet september 2011 Jan Martner SIR

2. In-hospital cardiac arrest Out-of hospital cardiac arrest Hospital ER ICU Survivors 10 000/year CCU/Ward Survivors

3. Year 2010 In-hospital cardiac arrest Out-of hospital cardiac arrest Survivors Hospital ER ICU n=1222 CCU/Ward Survivors SIR 2011

4. Year 2010 In-hospital admission 40% 60% ICU Out-of hospital admission SIR 2011

5. Longterm (180 days) Outcome 2010 In-hospital cardiac arrest 818 (67%) Out-of hospital cardiac arrest Hospital ER ICU 404 (33%) Survivors n=1222 CCU/Ward Survivors SIR 2011

6. N=275

10. N Engl J Med 2002 346 557 N=77

11. Results • Improved neurological outcome • Mortality: TH 51% vs no-TH 68% (ns.)

12. ILCOR recommendation: Unconscious adult patients with spontanous circula- tion after out-of-hospital cardiac arrest should be cooled to 32-34 oC for 12-24 h when the initial rythm was ventricular fibrillation (VF). Such cooling may also be beneficial for other rythms or in-hospital arrest. Resuscitation 2003 57 231-5

13. SBU's appraisal of the evidence The 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

14. Original publications in N Engl J M Alert report From SBU Start of Hypothermia Network Registry Report from Hypothermia Network Registry published 2002 2004 2006 2008 2010 2012 Recommended use by ILCOR

16. 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

17. Original publications in N Engl J M Alert report From SBU Widespread use of TH in Sweden Start of Hypothermia Network Registry Report published from HNR 2011 2001 2002 2004 2006 2008 2010 2012 SIR was born SIR 10 year anniversery Recommended use by ILCOR

18. Proportion of ICU patients with cardiac arrest receiving hypothermia treatment 2003-2010:

19. Proportion of hypothermia treatment according to hospital type

20. Proportion of patient recieving hypothermia treatment according to region 2004-2010

21. Proportion of patient recieving hypothermia treatment vs total number of cardiac arrest patients per ICU

22. Active cooling after cardiac arrest Out-of-hospital 2010 (N=791)

23. 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 ????

24. 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 ?

25. Tabell 1 - Jämförelse av patienter med och utan aktiv hypotermi Comparison of patients with or without activ hypothermia 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) a bedömt enligt APACHE-systemet (8)

26. Case study II:Active cooling after out-of-hospital cardiac arrest SIR data from 2005-2010

27. Registry studies vs RCT • Data quickly available • Reflects ”real life” conditions • Can easily be combined with other registry data

28. Original publications in N Engl J M Start of TTM trail Alert report From SBU Start of Hypothermia Network Registry Report from Hypothermia Network Registry published The use of TH is based on more solid data ? 2002 2004 2006 2008 2010 2012 Recommended use by ILCOR

29. 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