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Live at Annual Episode 4: Day 1 wrap-up

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Description

Day 1 of our 2023 Annual Meeting has come to an end and members of our Podcasting Committee reflect on their highlights from Phoenix. With Nick Morris, MD, Kassi Kronfeld, MD, Stephan Mayer, MD, and Jon Rosenberg, MD.

Contributors

  • Stephan A. Mayer, MD, FCCM

    William T. Gossett Endowed Chair of Neurology
    Henry Ford Health System
    Stephan Mayer is Chair of Neurology for the Henry Ford Health System in Detroit. He previously served as director of Neurocritical Care for the Mount Sinai Health System in New York and director of the Neurological Intensive Care Unit at Columbia University College of Physicians and Surgeons in New York. Dr Mayer earned his medical degree from Cornell University Medical College. He completed a residency in neurology and a fellowship in critical care neurology at the Neurological Institute of New York, Columbia-Presbyterian Medical Center. He is board certified in neurology and a founding member and past president of the Neurocritical Care Society. Dr Mayer has published more than 230 original research articles, 180 review articles, and 340 abstracts, and he has written 7 books, and co-edited the most recent edition of Merritt’s Textbook of Neurology. He was principal investigator of the FAST Trial, a worldwide multicenter clinical trial evaluating ultra-early hemostatic therapy for brain hemorrhage, and he served as principal investigator of the NIH-funded New York Presbyterian Hospital hub of the Neurological Emergencies Treatment Trials (NETT) network. His work in helping victims of severe brain injury has been featured in The Wall Street Journal and the book Cheating Death by CNN medical correspondent Dr Sanjay Gupta.

  • Kassi Kronfeld, MD

    Fellow in Neurology & Neurological Sciences
    Stanford Health

  • Nicholas A. Morris, MD

    Assistant Professor and Fellowship Director
    Division of Neurocritical Care and Emergency Neurology
    Department of Neurology
    University of Maryland School of Medicine Medicine

  • Jon Rosenberg, MD

    Jon Rosenberg is an Assistant Professor of Neurology and Neurosurgery at Westchester Medical Center New York Medical College and Associate Program Director of the Neurocritical Care Fellowship at Westchester Medical Center. 

  1. 00:00:21
    Hi, this is Nick Morris for the NCS
  2. 00:00:23
    Podcast, and we are live at annual.
  3. 00:00:26
    This is our wrap-up of today, and I'm
  4. 00:00:29
    with some of the members of the NCS
  5. 00:00:32
    Podcasts of Committee. Can we go around
  6. 00:00:34
    and introduce ourselves? Sure. So,
  7. 00:00:36
    I'm John Rosenberg. It's good to see
  8. 00:00:38
    everyone. Cassie Hronfeld, I'm here
  9. 00:00:40
    from Harbor, UCLA Stefan Mayer, past
  10. 00:00:45
    president, and I work with John as well,
  11. 00:00:48
    which is a true privilege. Well,
  12. 00:00:52
    thanks, everybody, for joining us,
  13. 00:00:54
    and I thought it would just be a nice
  14. 00:00:55
    way to wrap up today by everyone going
  15. 00:00:57
    around and sharing one highlight of the
  16. 00:00:59
    meeting so far from. So, John, why
  17. 00:01:01
    don't you get us started? Well, this
  18. 00:01:03
    is actually my first day at NCS ever,
  19. 00:01:05
    so it was nice to make it to the
  20. 00:01:07
    conference and see my colleagues. Lots
  21. 00:01:10
    of good learning I think for me, I did
  22. 00:01:12
    enjoy the brain death talk and just kind
  23. 00:01:14
    of under, I think, just understanding
  24. 00:01:17
    and seeing how there's a lot of
  25. 00:01:19
    heterogeneity and how. brain death is
  26. 00:01:21
    declared and how people adhere to the
  27. 00:01:23
    guidelines was a little kind of scary
  28. 00:01:25
    for me, but also nice to see that the
  29. 00:01:28
    society is taking this seriously and
  30. 00:01:30
    that there are going to be new
  31. 00:01:31
    guidelines coming out. What are those
  32. 00:01:33
    guidelines going to sag, you know? No
  33. 00:01:35
    CTA. And maybe I don't know what that's
  34. 00:01:39
    going to look like That's under embargo.
  35. 00:01:45
    I'm a big
  36. 00:01:47
    CTA fan when the rare circumstance when
  37. 00:01:53
    I have to get a confirmatory test
  38. 00:01:55
    because it's like easier and faster,
  39. 00:01:57
    you know? It's a 5 minute study.
  40. 00:02:20
    French. Right? Out of the God.
  41. 00:02:24
    All right, stuff on. What was you on
  42. 00:02:25
    your highlights today? I'm thinking
  43. 00:02:29
    about intrepid. But what was really
  44. 00:02:31
    interesting? I'm ready for intrepid and
  45. 00:02:34
    it was really fun today because it's a
  46. 00:02:36
    true reveal. It's like drumroll,
  47. 00:02:38
    please. But there's a little study of
  48. 00:02:42
    50 febrile and our critical care
  49. 00:02:44
    patients kind of sick, they're doing,
  50. 00:02:47
    they have sustained fever and they give
  51. 00:02:49
    half of them bromachryphine in addition
  52. 00:02:52
    to standard of care. So they've already
  53. 00:02:55
    been febrile for 24 hours after getting
  54. 00:02:57
    like, you know, a thousand milligrams
  55. 00:02:59
    Q6 of acetaminophen drumroll. It worked.
  56. 00:03:04
    It was really impressive. There was a
  57. 00:03:06
    really cool separation of the
  58. 00:03:09
    temperature curves and it was also they
  59. 00:03:11
    measured as an outcome escalation to
  60. 00:03:14
    like, you know, a servo controlled
  61. 00:03:17
    cooling device or something. And it was
  62. 00:03:19
    less escalation, it was really cool.
  63. 00:03:22
    You guys, it looks like you saw that,
  64. 00:03:23
    Nick, right? I did, I loved it.
  65. 00:03:25
    We've been using more and more
  66. 00:03:26
    bromo-cryptine. I think there's another
  67. 00:03:28
    recent paper that was published showing
  68. 00:03:30
    it works. And I've become a believer.
  69. 00:03:33
    And this, sometimes we kind of game the
  70. 00:03:36
    system, right? I think it's good for
  71. 00:03:38
    patient care, but it also can push
  72. 00:03:40
    patient care along because of all the
  73. 00:03:42
    procedures that get delayed because of
  74. 00:03:44
    fever, right? The trachin peg that
  75. 00:03:45
    gets pushed off, the transfer out of
  76. 00:03:48
    the ICU or to rehab that gets pushed off
  77. 00:03:50
    because they're spiking fever than
  78. 00:03:52
    someone's concerned. And we know that
  79. 00:03:53
    they seem to have these cyclic fevers
  80. 00:03:55
    that once a day they spike a fever and
  81. 00:03:57
    we're not gonna further work this up.
  82. 00:04:00
    And that just goes away, I think, with
  83. 00:04:02
    bromocarative. But I think what's kind
  84. 00:04:04
    of cool is that if you, mostly when you
  85. 00:04:06
    want to control febards in a
  86. 00:04:08
    neuropatient, that's gonna segue to
  87. 00:04:10
    intrepid, but the
  88. 00:04:14
    neuropatients are different And a lot of
  89. 00:04:16
    these savers are actually part of a
  90. 00:04:17
    cocktail problems that we think of, we,
  91. 00:04:21
    you know, classify storming. But I get
  92. 00:04:24
    it totally, like, by suppressing the
  93. 00:04:25
    storming, they look better, they look
  94. 00:04:28
    less sick, and you can move them a lot
  95. 00:04:31
    better. Yeah, and I guess you can keep
  96. 00:04:33
    a fully in for 14 days and not increase
  97. 00:04:36
    the risk of UTI. That was the big way
  98. 00:04:38
    we were able to try. How they defined
  99. 00:04:41
    UTI, you know, they ain't got to, but
  100. 00:04:43
    they're like, most of their attention
  101. 00:04:44
    is they don't look, right? You know,
  102. 00:04:48
    no culture, right? I don't dislike way
  103. 00:04:51
    off of that. So I guess my main
  104. 00:04:54
    takeaway from the Intrepid report out,
  105. 00:04:55
    and hopefully Dave Guru doesn't come me
  106. 00:04:57
    down after this, was that we don't know
  107. 00:04:59
    yet, is fever just a sign that the
  108. 00:05:01
    patient's going to do poorly? And we
  109. 00:05:03
    know fevers happen in brain injury, but
  110. 00:05:06
    we just still don't know. Does
  111. 00:05:07
    intervening on that fever change the
  112. 00:05:09
    outcome? So I thought that was actually
  113. 00:05:12
    really a good take back moment kind of,
  114. 00:05:15
    you know, take a step back, reevaluate
  115. 00:05:16
    what we're doing and say like, wait,
  116. 00:05:18
    are we the wrong thing is the fever just
  117. 00:05:20
    the sign of something else and it's not
  118. 00:05:22
    really the key to the intervention.
  119. 00:05:24
    Well and right the only main differences
  120. 00:05:27
    in the two groups were the fever burden
  121. 00:05:29
    and shivering which is like duh of
  122. 00:05:31
    course right um but if if you control
  123. 00:05:35
    fever without shivering that's that's
  124. 00:05:37
    all another question it's out there
  125. 00:05:38
    right and so um you know my my boss near
  126. 00:05:42
    just been working on this for a while
  127. 00:05:43
    only these intranasal devices and I
  128. 00:05:45
    think that's uh still fair game is we
  129. 00:05:48
    have to answer this question is how
  130. 00:05:49
    deleterious is shivering and if there is
  131. 00:05:52
    a way to control fever without shivering
  132. 00:05:55
    is that worth pursuing maybe
  133. 00:05:57
    bromocrypton is the answer I don't know
  134. 00:05:58
    because the shiver on bromocrypton well
  135. 00:06:00
    that's fine it's not part of the uh the
  136. 00:06:02
    classic columbia stepwise you know to
  137. 00:06:04
    shiver protocol which hats off to nary
  138. 00:06:08
    she you know really came up with that
  139. 00:06:10
    team effort obviously but that's I mean
  140. 00:06:13
    presumably you're you're doing that
  141. 00:06:15
    you're doing you know the magnesium Nipu
  142. 00:06:17
    Speron.
  143. 00:06:19
    and the skin counter-warming, and then
  144. 00:06:21
    I love the duck-spent automating, right,
  145. 00:06:24
    and, you know, so you don't have to,
  146. 00:06:26
    it is true, like, if you zonk people.
  147. 00:06:29
    I don't know if people know this, but
  148. 00:06:30
    in the very beginning, when we were
  149. 00:06:32
    doing TTM, we're pulling blankets and
  150. 00:06:33
    catheters, they were going directly to
  151. 00:06:38
    the parody, and that was it, and just
  152. 00:06:41
    getting zonked, and extending the
  153. 00:06:44
    length of stay, and getting more
  154. 00:06:46
    pneumonias, and the whole thing, so.
  155. 00:06:49
    Yeah, but they, we'll see the
  156. 00:06:51
    publication, right? They will, they
  157. 00:06:53
    will.
  158. 00:06:56
    Any other thoughts about the meeting?
  159. 00:06:57
    Yeah, it's just nice to be back in
  160. 00:06:59
    person, this is my first meeting since
  161. 00:07:02
    I graduated fellowship, really nice to
  162. 00:07:03
    connect with people, and meet new
  163. 00:07:06
    people as well. Yeah, Nick, what do
  164. 00:07:08
    you think of the weather? It's hot,
  165. 00:07:11
    it's real hot, it's not a little hot,
  166. 00:07:13
    it's hotter than hot We walked two
  167. 00:07:15
    blocks to get tacos and I was sweating.
  168. 00:07:18
    my shirt and before I even got there.
  169. 00:07:21
    But John, your family's from here.
  170. 00:07:23
    We're from New York, moved here about
  171. 00:07:25
    2000, about 20 years ago. But this is
  172. 00:07:29
    a hot time. The weather's going to
  173. 00:07:31
    break. And typically also in Phoenix,
  174. 00:07:34
    it's in a valley and it's also a lot of
  175. 00:07:36
    concrete. So it's a little warmer here
  176. 00:07:38
    than the rest of like, you know, if
  177. 00:07:39
    you go a little further north, you know,
  178. 00:07:41
    maybe 105, not 110 or 100, not 110.
  179. 00:07:44
    Well, this is why NCS usually is in
  180. 00:07:46
    October, right? So we picked a really
  181. 00:07:48
    good time of year. I hope we're going
  182. 00:07:50
    back.
  183. 00:07:52
    Well,
  184. 00:07:54
    no, no news there is hot in Phoenix,
  185. 00:07:57
    but really exciting studies that were
  186. 00:08:00
    released today, new results at NCS,
  187. 00:08:02
    which is unusual for us. And I think
  188. 00:08:03
    moving this conference a step forward
  189. 00:08:06
    and its importance is getting results
  190. 00:08:08
    from a major trial like Intrepid for the
  191. 00:08:11
    first time. So that's really exciting.
  192. 00:08:13
    And hopefully there'll be more of that
  193. 00:08:15
    in the future at the neurocritical care
  194. 00:08:17
    and no meeting. you guys are going to
  195. 00:08:19
    do one bar drain. We've already started
  196. 00:08:21
    one bar drains. We have done over 80
  197. 00:08:23
    patients. We started before the early
  198. 00:08:25
    drain trial was released. We talked
  199. 00:08:28
    about on the podcast earlier today.
  200. 00:08:29
    We've changed a little bit of our
  201. 00:08:30
    protocol based on the early drain
  202. 00:08:32
    protocol because we did have some safety
  203. 00:08:35
    concerns with some brain sag from over
  204. 00:08:37
    drainage. And I think this dual
  205. 00:08:40
    measurement looking for a gradient
  206. 00:08:42
    between the EVD and the one bar drain
  207. 00:08:43
    pressures helps protect against that.
  208. 00:08:46
    So we're going to start as well. It's a
  209. 00:08:48
    lot of interest.
  210. 00:08:51
    All right. Well, thanks everybody.
  211. 00:08:53
    Keep tuning in to live at annual for
  212. 00:08:56
    your updates on the annual neurocritical
  213. 00:08:58
    care conference. We're excited to bring
  214. 00:09:00
    this content to you and we hope you'll
  215. 00:09:02
    keep downloading the NCS podcast
  216. 00:09:04
    wherever you get your podcasts.