Professor Cronberg has been working with cooling technologies for over 20 years and is a senior member of the team behind the world wide Targeted Temperature Management 2 (TTM2) trial. The trial is a continuation of the original TTM trial and with almost 2000 patients enrolled, it will supercede it as the largest trial on temperature management as a post-cardiac arrest intervention.
Professor Cronberg talks about the history of cooling and what the study hopes to achieve and where it currently is. A fascinating overview of this intervention that many cardiac arrest patients will have received as part of their treatment.
#044 Post arrest cooling with Professor Tobias Cronberg
Paul Swindell: [00:00:00] Hello, and welcome to another episode of the life after cardiac arrest podcast with me, your host, Paul Swindell.
Today I'm joined by professor and consultant in neurology at Lund University, Tobias Cronberg, who has a special interest in cardiac induced brain injuries.
Welcome to the show, Tobias, and it's great to talk to you.
Professor Tobias Cronberg: [00:00:32] Thank you, Paul. Very nice to be here.
Paul Swindell: [00:00:35] And just to say that you're in Sweden at the moment, aren't you? How's life there?
Professor Tobias Cronberg: [00:00:41] Well, the sun is blue, and the sky is up, but of course we are suffering from the pandemic as everybody else. So, it's an extraordinary situation,but it hasn't hit the Southern part of Sweden very much. Yeah. So, we are still very, and much business as usual.
Paul Swindell: [00:01:01] Yeah. So, you're just saying before we started recording your life seems not quite normal, but it's not as drastically hit as it is in the UK.
Professor Tobias Cronberg: [00:01:11] That's right.
Paul Swindell: [00:01:11] And I just wonder if you could briefly introduce yourself and tell me a little bit about your interest in neurology and in particular, cardiac arrest induced brain injury. How did you come into that?
Professor Tobias Cronberg: [00:01:24] Well, I tried to make a long story short, it started actually during my, my early years in Lund from, the middle of the 1990s when I was working in a laboratory doing my PhD in experimental brain research. And we worked a lot with stroke models and with a models of cardiac arrest, and the basic mechanisms of cell injury after cardiac arrest and stroke, which is rather similar diseases in the sense that the blood it gets a loss of blood flow for a period, and then we have a reperfusion of the brain and then we have a damage, and the mechanisms are quite similar, actually.
So, it started then and when I, I had done my dissertation, I was working full time clinics and I got interested in the cardiac arrest population.
I started a collaboration with Hans Freberg, who was intensive care physician at that time, and he was a professor there and now, we started, with hypothermia treatment early in 2003 when, when the two important studies were published, showing that cooling patients after cardiac arrest had a protective effect.
And we were strong believers of hypothermia and we wanted to, to study outcome in those patients long-term outcome, and also to look at different methods to try to diagnose brain injury and to try to decide the prognosis for the patients, in the ICU, when the patients were still unconscious, and we started working with different methods, mainly biomarkers in the blood, clinical neurological examination and, electrophysiology, where we could work would continous EEG, for example, as a method to look at the brain activity after cardiac arrest, we started publishing our results about this and, gradually, we got more and more international collaboration. Nicholas Nielson, who is intensive care physician in Helsingborg became part of the team and he was very important for us building up a big network of international sites in the hyperthermia register, which was the foundation for the first TTM trial. After that, which we did in 2010 until 2013, studying the effects of, temperature management in patients.
Paul Swindell: [00:04:04] When was it sort of first realized that hypothermia could be sort of therapeutic and be a useful tool in the medical toolkit as it were. I mean, I guess people have known for quite a long time. I mean, when I used to play sports as a youngster and I, if I got a strain on my leg, you get an ice pack put on your, on your knee or the muscle or whatever, and that would help alleviate any inflammation there.
And you get back to playing the sport quicker, but when was it sort of the light bulb moment, if you like that, Hey, we can use this in a bigger way for something like the brain?
Professor Tobias Cronberg: [00:04:43] Well, that has been known for the, for the brain. It has been known for many years, that it's possible to cool a patient, for example, to, be able to do thoracic surgery in the main aortic vessel, to be able to stop the blood flow to the brain you have to cool the patient very much all the way down to two 19 degrees.
At that level it's, it's almost like putting the brain into the refrigerator and all biological processes slow down, very much. Very similar to what happens in your knee, actually. You slow down all the biological processes, all the damaging, degrading processes are being slowed down and, for a patient operated and, thoracic surgery, you could, you could do, keep operating for approximately one hour at the temperature of 19 degrees.
And during that period, you have basically no activity in the brain. If you, if you look at the cortical activity with an EEG, it's completely silent and then you could rewarm the patient and they will be functioning, more or less normally after that, maybe some, some minor problems, but most patients could return to normal life.
And, comparing that with a cardiac arrest, it would be completely impossible to have a human who, who is without any circulation and normal body temperature for one hour. After that time, you're certainly dead. There's no chance to, revive that person, if the body temperature is normal. So, it has been very obvious and it has been known, for a long, long time.
But, there were, early research, on this, I'm not sure about the exact years, but there were pioneering research done in, in the U S in Pittsburgh at the Safar Institute, and then it was more or less abandoned until the 1970s, when this, when there was some major new focus on hypothermia in experimental settings and a lot of experimental done.
In, in animals, with mild hypothermia, not down to 19 degrees, but only two 33 to 32 33, or maybe 34 degrees, and it was shown that this was effective in different models, experimental models of cardiac arrest and stroke. So, when I got to the lab laboratory and started my research in 1995, it was very well known.
I mean, that laboratory here in Lund, a lot of the pioneering work had also been done on hypothermia in experimental animals. And for me it was very clear. Also, I worked with the whole animal models, and I also worked with cell cultures and when we did this scheme in the cell cultures, and we just lowered the temperature.
The cells didn't get damaged. So it was, it was sort of a concept that was, very much for all the researchers. Very, very clear concept that hypothermia works. And then we had these two trials in 2013 showing in a clinical setting that it worked also in patients. And that led to a major implementation over the whole world, of hypothermia treatment.
But unfortunately, those two trials were not, very good trials, they were small trials. One Australia trial from, from, Bernard and his collaborators, which we'd only less than 100 patient, I think it was 77 patients. And then as European trial, which was stopped early because they didn't have enough funding and they had, I think, 200 and, and 73 patients, which is not very much in these suction circumstances. So, so for us later, it became evident that we need more information in patients, to know whether it is effective or not. We need to do large clinical trials to study, temperature management, hypothermia treatment in patients.
Paul Swindell: [00:09:09] Could I just take you back to one of the things you were saying when you were doing your study and your PhD, you were saying you were looking at animals.
Do animals though, that they have, a lot of them have a natural ability to hibernate anyway, don't they? So how does that come into the picture and do humans have anything like that?
Professor Tobias Cronberg: [00:09:26] No, humans don't have that ability to hibernate, and, and the animals used, in the experiments for hypothermia, don't have that ability. So a rat, which is the most common laboratory experimental animal, it can�t hibernate, and pigs has also been used, but not very much.
But the animals, rats and mice, they don't, they don't hibernate.
Paul Swindell: [00:09:51] And, and also, as I mentioned to you just before we came on, on the air,
There was a, famous case at the end of the nineties, which featured a, a Swedish doctor Ana Bagenholm, who I believe, experienced a case of hypothermia for a couple of hours, I believe it was, cause she was skiing in Norway and, fell into a river.
Do you know much about that?
Professor Tobias Cronberg: [00:10:14] Yes, I remember. I know I've seen a program on television about her.
Professor Tobias Cronberg: [00:10:19] This, this is a very, very interesting case and it's sort of a proof of principle case. With Ana Bagenholm because what happened was that she was skiing, and down a slope and she went out on the ice at the end of the slope and was sliding out on quite thin ice, actually, and got trapped with her head into the water, and was, and drowned, on the ice with her head being put into the water, and then she had a cardiac arrest, if I've understood it correctly. So, so this is not an unusual situation with cardiac arrest, in the circumstance of drowning, of course.
But what was very special with Anna Bagenholm and ideal for her was that her body, and particularly her head was cooled before she had the cardiac arrest.
And we also know that from experimental settings that the most protective effect of cooling is if you could the brain of the animal or of the human in this case before the heart stops. Because then all the damaging processes will be much slower.And for her, they couldn't rescue her because of the thin ice.
So, her friends couldn't, couldn't rescue her, and they eventually got a helicopter and somehow they rescued her and she was transported and put on, on, artificial circulation in the helicopter. And slowly rewarmed and very, very slowly, her heart started beating again.
And it was so remarkable because she had at least, I'm not sure how long, but at least one hour of circulatory arrest. And that's very similar to these thoracic surgery patients. And, and that explains why her brain didn't get damaged or more damaged, by the cardiac arrest.
Paul Swindell: [00:12:19] I understand that she was like, over two hours in arrest and her body temperature went down to 13.7 degrees, which apparently was the lowest ever recorded. And it's pretty amazing. But I don't know if you saw the news last year, towards the end of last year, there was a report of a British lady who had a similar case who suffered hypothermia in the mountains of Spain.
And she arrested for, six hours, I think it was. But they managed to bring her back, and they always say, "they made a full recovery", but of course, we're never really know whether she has made a full recovery.
Professor Tobias Cronberg: [00:12:59] No, but it's, I think it's a very, very strong and important message here. And that is if you are cooled before you have the arrest, then you have a very favorable situation.
And that's also very well known to doctors that you cannot decide that the person is dead.
Before the person has been rewarmed, because there's always the chance that the cooling or the chill has had a protective effect and not the patient will survive.
Paul Swindell: [00:13:31] There's a saying isn't there?
You're not dead until you're warm and dead.
Professor Tobias Cronberg: [00:13:35] Exactly, exactly. And it's also interesting, we did a meta-analysis of the experimental data on hypothermia after cardiac arrest, all the animal research we put together. And looked at the evidence in favour of hypothermia. And it showed that the strongest evidence is for, prearrest cooling or intra arrest cooling of the small animals.
And we have actually. All too few data on large animals with post cardiac arrest cooling, which is what we do with the humans. When, when we are cooling after arrival to hospital.
Paul Swindell: [00:14:17] Obviously we don't know for My cohort, for people like myself, we don't know. The majority of them are going to go into an arrest. So, we can't really put us into a cooling situation firsthand unless you, you're there by chance. But do you think it would, I don't know if the technologies are there, but, in first aid situations with paramedics and things like that, would they have cooling apparatus with them?
Would that be a practical scenario for them to adopt in the future if they know that, you know, as well as getting a defib and doing CPR that we get a cooling pack, whatever that looks like? I don't know. But is that something that you could see perhaps coming in the future?
Professor Tobias Cronberg: [00:15:02] Well, we can certainly, we can't exclude it, but there have been studies trying that approach because it's so obvious for, from, from experimental studies that it would be a great advantage. So there has been a big study looking at the prehospital cooling with intravenous cold fluids, but that did not show any benefit, some signal towards harm, because cold fluids will give you a load on the heart.
So, there's a risk of, cardiogenic shock. The patients will go to shock because of the fluids. So that was not a good approach. And then there was a, study, which was, centered from Stockholm in Sweden, with, with nasal cooling, where they try to call through the, nose. Most of the patients with a special technique, uh, with preparation and, that didn't show any effect. however, a small signal to boards possible effect, at least the context included that it may have some effect, but it was not a significant can't affect anyway. And I, it may tell us that it's the main, main thing if a person has a cardiac arrest, is to get the heart restarted.
And if we start doing other things, maybe we won't be as successful restarting the heart.
Paul Swindell: [00:16:30] That�s true, that�s true.
Professor Tobias Cronberg: [00:16:31] So there are, there are problems with any approach. And if we compare a human to a mice or a rat, well, it's much more difficult to cool a human. You can't just put a few ice packs. It won't too much difference to lower the body temperature of such a big animal, lesser human.
It takes a lot of time and a lot of effort and a lot of cooling power.
Paul Swindell: [00:16:59] Okay.
So, can we go back to sort of the turn of the century? It sounds a funny sort of phrase. So back, back at the early two thousands, you said, you noticed that, it was obvious that cooling worked for you. So, you started doing that in your hospital then presumably.
Professor Tobias Cronberg: [00:17:14] Yeah, that's true.
Paul Swindell: [00:17:19] What did you start seeing?
Professor Tobias Cronberg: [00:17:21] Well, it was a great enthusiasm. And the big thing I, I think at that time was a shift in favour of the cardiac arrest patients. They became a very interesting patient group in the ICU because suddenly the cardiac arrest went from being a condition where we could do nothing, to become a condition where we could do a lot because we could do cooling with the cooling machines, fancy new apparatus.
I think that was very good for the cardiac arrest patients. And, and, it was shown in, in many registers that, survival, went up after the introduction of, cooling. I think that's important too, to remember as well that, probably many things improved for the cardiac arrest patients because before that time, it wasn't obvious that a cardiac arrest patient would go to the ICU.
They may go even go to a regular ward without any artificial ventilation, and now because they needed to be sedated and not officially ventilated during the cooling process, they probably got very good intensive care, in the package, so to say.
Also, we started with a more advanced methods to diagnose brain injury, to, to be able to do a more advanced prognostication to decide which patients would have a good outcome eventually in which patients had such severe brain injury that it wouldn't be beneficial to continue treatment.
And that was also probably very good for the patient. It made it the care more safe and the decisions around life sustaining therapy more safe, I think.
Paul Swindell: [00:19:10] What would these patients, in hospital cardiac arrest victims or were they out of hospital or were they both?
Professor Tobias Cronberg: [00:19:17] Both. Both. we didn't make any difference whether it was in the hospital or out of hospital. for in hospital cardiac arrest patients, they often have more significant comorbidities because they're in the hospital for a reason. And that may be a reason not to. To give full intensive care, for example, for a patient with advanced, cancer of some kind, may not be of benefit for the patient to have that care path.
But those decisions have to come later. When a patient have a cardiac arrest, it's a full action and full intensive care from the beginning. And then you can, you can sometimes have to back off.
Paul Swindell: [00:20:02] What was the scenario in Sweden at that time?
Cause there's sort of general consensus from the UK is that the Scandinavian countries are ahead of us in the curve. As it were, regarding having AEDs in the community and encouraging people to do CPR and having the equipment and the processes in the hospital once you get there.
Professor Tobias Cronberg: [00:20:23] I wouldn't say, I think, I think at this that the curve is lifting around that time around 2000, around 2000 or even, even later. So, I think you could see the real surge in, in survival rates in Sweden comes after the introduction of hypothermia. But at the same period, there is a lot of training in CPR in the community, and there is a public movement of, lay people, CPR.
it's around that time and, and we have seen very clearly in the Swedish cardiac arrest register, how survival and the use of bystander CPR are parallel curves.
Paul Swindell: [00:21:21] So you've been doing, therapeutic treatments for a while then, and then, had that been spreading around to other hospitals and to other parts of the world? And then what, what was the motivation for coming up with the TTM, trial? The initial one.
Professor Tobias Cronberg: [00:21:37] Yeah. So, so the, the introduction or the implementation of therapeutic hypothermia was a global movement. And, a lot of believers, who had been doing experimental research perhaps, or were just doing clinical research. We're implementing these treatment all over the world in a parallel process.
So, it wasn't something that spread from Lund to a other places, certainly not, but it spread from many places. And there is still a very much of a movement and a great interest in hypothermia all over the world. But the TTM. So, we were also part of the believers, because we had so much evidence from the experimental research.
As we, as we thought, at least, and then Nicholas Nielsen, he did a meta-analysis, of the clinical evidence for therapeutic hypothermia, together with the clinical trials unit in Copenhagen. Copenhagen is very close to Lund, it's just over the sound here. And we have a lot of collaborations. And Nicholas works with very good statisticians and clinical trialists in Copenhagen, and they could show that the evidence, for therapeutic hypothermia in humans were insufficient, and that, it could be a benefit or it could be no benefit, or it could even be harm.
We couldn't tell from the studies that were performed. And I think that changed something fundamentally for us, in the group. And we decided to, do a large international trial and we started to, form the group around the TTM. The first TTM trial when we were discussing the TTM trial, we first thought that we would just redo the previous trial.
Test whether coding is better than no coding, but since the guidelines at that time, they recommended cooling for these patients. We many people thought it would be unethical to randomize patients to know cooling. Since, since a lot of people all over the world thought that it was shown. That cooling was working and the guidelines stated that it was shown or there was evidence, strong evidence in favour of hypothermia.
So that therefore, the first TTM tried was a bit of a compromise where we decided to, just to compare two different targeted temperature, 33 degrees and 36 degrees. Temperature where 36 was quite similar to no treatment or as far as we could go in that direction. And then we did this very large trial with 950 patients, so it's much more than the other trials together.
And we saw absolutely no difference between 33 and 36 degrees. And I think that was very, very surprising for many people in the field because from the experimental research, we should certainly have a very big difference between 33 and 36 but we didn't, and we looked at a lot of different outcomes for the patients.
Of course, survivor level, of cause neurological function at six months after the cardiac arrest, and we looked at cognitive functioning detail, we looked at biomarkers of brain injury in the blood. And we saw no differences between the groups. So, so that led to a change in the recommendations from the international organizations that, 33 or 36 degrees is just, just as good.
Paul Swindell: [00:25:22] You still felt that cooling was better than no cooling?
Professor Tobias Cronberg: [00:25:27] Well, I felt that we needed to take it all the way. I didn't feel that, I personally, I didn't feel very strongly that cooling was better than no cooling. I felt that the may be in effect still, but I'm, I'm not sure. And I'm still not sure because we are still doing the TTM 2 trial. I think it's a, I think it's equally possible that there is no effect of cooling.
That there is, is an effect.
Paul Swindell: [00:26:01] Oh, interesting. So what, what is it the people who, say that cooling works, what is it they think is actually happening with the, with the brain and with the body when you actually call someone? What, what processes are we changing?
Professor Tobias Cronberg: [00:26:14] Well, we are certainly doing a lot of things in the brain when we see, when we cool a patient that's no doubt about it. I mean, we. We slow down all the biological processes. It's just the same as when you take your milk package of milk and put it in the refrigerator. You protect the milk from, from breakdown, and you protect the brain from, from breakdown and damage due to a lot of different processes that has been shown in the experimental animals.
And we have proof of principle. Well, w with this, physician who went into the cold water, as you, as you referred to, and, we have from patients being cooled for thoracic surgery, we know that it's very a very potent, treatment, but we don't know if. When we do it in a delayed fashion as we do with the patients today, if that is effective.
And that's my major doubt. I'm doubt that, that we do it early enough, I think we would need to be much faster, and have some kind of method to very effectively, without any side effect cool the patient, on the scene.
I doubt that it is effective to do it, as, we do it.
Paul Swindell: [00:27:35] So you think that the damage is already done as it were?
Professor Tobias Cronberg: [00:27:39] Exactly, exactly
That's what I'm afraid of. At least that we are not, we are not, protecting the brain early enough
Paul Swindell: [00:27:49] And I guess that comes back to what we briefly talked about earlier, getting the paramedics, equipment to be able to do that. But then, as you said, that adds another, another job to be done, as well as trying to restart the heart, which is obviously the most important thing to do.
So, its a tricky one isn�t it really?
Professor Tobias Cronberg: [00:28:08] Yeah.
So, this would, with hypothermia treatment or targeted temperature meat treatment is something that we will be living with for many years to come, I'm sure. And we will have to work with it and try to refine it to get as much as possible out of the treatment. But I'm not sure that what we are doing today, is effective
Paul Swindell: [00:28:31] are most hospitals these days might do most cardiac arrest patients say in, developed nations, will they experience the calling that, you�ve been talking about?
Professor Tobias Cronberg: [00:28:41] Yes, I would say so. Certainly, in the Scandinavian countries, but it varies over Europe and it varies globally as well. I think it's a lot more variations in the in the U S but there's big variations within Europe as well.
Paul Swindell: [00:28:59] you're currently undertaking a TTM 2, so how does that differ from your original trial.
Professor Tobias Cronberg: [00:29:05] Yeah.
So, in the TTM two we are taking the question one step further. We are now trying to evaluate whether hypothermia to 33 degrees as in the TTM one trial compared to no cooling unless the patient gets fever.
So, we're in the control group. We will only treat those patients who develop fever, which is about a temperature above 37.8.
So, if a patient gets 37.8, we will take them down to 37.5 and, and keep them there with the cooling device, for the first, 24 hours.
Paul Swindell: [00:29:45] Do people naturally go into a fever after they've had a cardiac arrest?
Professor Tobias Cronberg: [00:29:50] Yes, many people develop a fever of the cardiac arrest, and that's part of probably part of the global, systemic organ damage with a global, inflammatory process in the body.
So, it's common that you develop fever and the more fever you develop, the worst is your prognosis. It's related to worst prognosis to have fever.
So that's a, the reason why there is a recommendation to treat fever, and it's the same in stroke. Actually, there's a recommendation to treat fever because there is an association with the worst outcome.
However, whether we are actually doing something good by cooling, we don't know, because it may be that it's just a marker of a more severe damage.
So, so we don't, we don't even know that for sure, but we thought that in the TTM 2 trial, we will take it just one step further and decide whether cooling for patients who do not develop fever, whether that is any good or not.
Paul Swindell: [00:30:54] Yeah, that's interesting. And so how far along are you in this trial?
Professor Tobias Cronberg: [00:31:00] The TTM two trial has included 1900 patients just as planned. It's the largest cardiac arrest trial ever performed, and we are now performing the follow-up, the six months follow up and trying to complete it. It has been, a problem with the covert pandemic of course, because we can't see the patients face to face.
We have to do follow ups, with telephone instead. But we are, are pressing on with our, schedule and we believe we will be able to publish the results in the end of this year or the beginning or next year.
Paul Swindell: [00:31:39] Okay that�s great.
So, what are the outcomes you're looking for? Is, is it just, not that they survive, but they survive with particular or better neurological outcome, is it?
Professor Tobias Cronberg: [00:31:46] Yeah, certainly we are looking at different things, but the primary outcome is survival. And that's because it's a very robust thought. I'll come off the cardiac arrest. You can't really, you can't, you can never manipulate survival, either you survive or not, and if you can't get any, any kind of influence from your own perceptions into that, but the secondary outcomes is quality of life.
Of the survivors and also their neurological function in more detail. And then we have a lot of exploratory outcomes where we are looking at their cognitive function, their physical activity, and how they are, are participating in, in the community, et cetera, et cetera.
Paul Swindell: [00:32:35] Okay. So, you say you'd be publishing next year, and then do you get a feel for whether this is, been a, a benefit doing TTM two as opposed to TTM one?
Professor Tobias Cronberg: [00:32:47] Yes, I think. I mean, it will have a fundamental impact. If we can show that hypothermia is, or cooling to 33 degrees is effective, then I think a lot more centers will start using this treatment all over the world. That will be a very, very strong signal for, for working, to refine, hyperthermia treatment as well.
But if we don't show any effect, that will be to the other side. People will probably stop doing hyperthermia for patients who don't have fever, that will also have a fundamental effect. So, I think the world is sort of rather much, the or the cardiac arrest community's rather much waiting for the results of the TTM to try and.
Paul Swindell: [00:33:33] Yes. Yes. I can understand that. A lot A lot of weight on your shoulders.
Professor Tobias Cronberg: [00:33:38] Yes, yes, it is.
Paul Swindell: [00:33:41] I'd just like to finish off this, conversation about, therapeutic management is, it's sort of throw you a left field type question.
Do you think we can use this sort of technology, to put humans into a sort of pseudo hibernation so that maybe it can be used in other fields like space travel or preserving people so there life span is longer?
Professor Tobias Cronberg: [00:34:04] No, I don't think so, no.
Paul Swindell: [00:34:08] No?
Professor Tobias Cronberg: [00:34:09] I don't know, but to slow down, your metab, metabolism may be good for you. It may make you live longer. There are some, I mean, some, some data that the starving is slow grade starving will make you live somewhat longer. Cooling down the body and then re awake patient or a person, I don't know. It's signed. It's sort of a scientific future that I don't, I don't want to be part of, at least I think we are so many people on the world anyhow so we should leave space for those coming after us, but that's more ethical issue I guess.
Of course, I mean, hypothetically cooling down somebody and putting them in a spaceship and having some, some, machine to thaw them when they arrive. It's, yeah, theoretically you may be right. Maybe, maybe possible for long travel is extending over a hundred years or something like that.
Paul Swindell: [00:35:13] Or maybe, even though I don't know if for shorter periods, like getting to Mars or coming back from, there can be a couple of years, I believe, if, if you, leave at the wrong time in the orbit,
Professor Tobias Cronberg: [00:35:25] Yes, yes. I think you could, I mean, probably you could extrapolate from, from the, from your package of milk again, that putting the milk in a refrigerator will buy you some time, but not a lot of time. A few days, for, it gets sour, but putting it in the freezer would buy you a lot more time, I mean, it's still a limited time and putting a human in a freezer. I don't think we will be able to thaw them afterwards because there is so much cell damage.
Paul Swindell: [00:35:59] It�s not all good news being in the freezer.
Professor Tobias Cronberg: [00:36:02] No, I don't think so.
Paul Swindell: [00:36:08] Okay. Tobias, thank you very much, has been a really interesting conversation about this subject, which is, you know, it's, it's played a part in my recovery and I'm sure that played a part in many other people's recovery as well. And I'm, really glad that you guys are looking at this subject and that you did back in.
Back at the end of the nineties, last century. And it's going to be really interesting to see the results of the TTM 2 and where that takes us.
So, good luck with it all and I hope we speak again soon
Professor Tobias Cronberg: [00:36:38] Thank you, Paul. I just want to say a last word and that is that even if we would, show that therapeutic hypothermia is ineffective in the way we use it today, it wouldn't mean that the treatment has not been beneficial for the patients. I think it has been tremendously beneficial. Because a lot of things came with the package, had a lot more focused on the cardiac arrest patient in the ICU.
A lot more, more, artificial ventilation of focus on that, sedation regimes, EEG, surveillance, et cetera. And we will talk more about that
Paul Swindell: [00:37:15] Yes, it's very valid points and yeah, thanks for raising them.
Alright, Thanks a lot. Bye. Bye.
Professor Tobias Cronberg: [00:37:18] Bye
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Presented and edited by Paul Swindell.
Recorded April 2020.