None of this would have been possible a decade ago. Truly, it was interesting to watch and another collective win for free open access medical education (FOAM).

The EMCrit podcast featured interviews with both Jon Rittenberger, MD, MS, associate professor of emergency medicine at the University of Pittsburgh, who coauthored the accompanying New England Journal of Medicine editorial of the trial, and Stephen Bernard, MB BS, MD, senior intensivist at The Alfred Hospital and director of intensive care at Knox Private Hospital in Victoria, Australia, and lead author of the 2002 Bernard trial.

Dr. Rittenberger interprets the TTM trial as affirmation that targeted temperature management works, only more research may be necessary to find the appropriate temperature for every subpopulation. For instance, in patient populations stratified by their organ dysfunction, the most severely brain-injured patients may still benefit more from deeper degrees of hypothermia.

In what may be the most compelling affirmation of the TTM trial, Dr. Bernard calls the study “outstanding science” that “ticks all of the boxes for an influential [randomized controlled trial].” In a display of intellectual integrity, Dr. Bernard has adopted 36°C in his ICU but adds that patients who undergo intra-arrest cooling may still benefit from cooler temperatures. Dr. Bernard also plans to adopt the TTM trial’s standardized system for prognostication.

Other experts, such as Kees Polderman, MD, of the University of Pittsburgh, Simon Carley, MB ChB, of the St. Emlyns blog (www.stemlynsblog.org), and Mike Cadogan, MB ChB, of the LifeInTheFastLane blog (www.lifeinthefastlane.com), offer a more skeptical interpretation of the data. Some of their more compelling arguments are summarized below. But first…

Please Don’t Stop Cooling Your Post-Arrest Patients!

Before getting into any more details, it is imperative to address this far too common misconception of the TTM trial. It is important to keep in mind that the Bernard and HACA trials of 2002, which helped establish 33°C as the standard of care in aggressive treatment of post-arrest patients, compared moderate hypothermia (32°–34°C) to no active temperature management at all. The average temperature of the control group in the HACA was 37.8°C, and it is plausible that even this mild elevation of temperature could absolutely be detrimental to the injured brain.

We know that TH works and fever in the post-arrest state is bad. The TTM trial does not contradict earlier studies. It was a dose-finding trial, not a trial of hypothermia versus no hypothermia. It’s a trial of tight temperature management at one temperature versus another. This is similar to trying to find the best dose of a drug.