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Ross CE, Parker MJ, Mentzelopoulos SD, Scholefield BR, Berg RA. Emergency research without prior consent in the United States, Canada, European Union and United Kingdom: How regulatory differences affect study design and implementation in cardiac arrest trials. Resusc Plus 2024; 17:100565. [PMID: 38328747 PMCID: PMC10847942 DOI: 10.1016/j.resplu.2024.100565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Aim A major barrier to performing cardiac arrest trials is the requirement for prospective informed consent, which is often infeasible during individual medical emergencies. In an effort to improve outcomes, some governments have adopted legislation permitting research without prior consent (RWPC) in these circumstances. We aimed to outline key differences between legislation in four Western locations and explore the effects of these differences on trial design and implementation in cardiac arrest research. Data sources We performed a narrative review of RWPC legislation in the United States (US), Canada, the European Union (EU) and the United Kingdom (UK). Results The primary criteria required to perform RWPC was similar across locations: the study must involve an individual medical emergency during which neither the prospective subject nor their authorized representative can provide informed consent. The US regulations were unique in their requirements for performing Community Consultation and Public Disclosure in the communities in which the research takes place. Another major difference was the requirement for consent for ongoing participation in Canada, the EU and the UK, while only notification of enrollment and the opportunity to discontinue participation are required in the US. Additionally, only Canada and the EU explicitly state that the subject or their representative may request withdrawal of their data. Conclusion Regulations governing RWPC in the US, Canada, the EU and the UK have similar goals and protections for vulnerable populations during medical emergencies. Differences in the qualifying criteria and implementation procedures exist across locations and may affect study design.
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Affiliation(s)
- Catherine E. Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Melissa J. Parker
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children’s Hospital and McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada
| | - Spyros D. Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Barnaby R. Scholefield
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Honorary Associate Professor, University of Birmingham, UK
| | - Robert A. Berg
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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Parker MJ, Thabane L, Fox-Robichaud A, Liaw P, Choong K. A trial to determine whether septic shock-reversal is quicker in pediatric patients randomized to an early goal-directed fluid-sparing strategy versus usual care (SQUEEZE): study protocol for a pilot randomized controlled trial. Trials 2016; 17:556. [PMID: 27876084 PMCID: PMC5120449 DOI: 10.1186/s13063-016-1689-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 11/09/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Current pediatric septic shock resuscitation guidelines from the American College of Critical Care Medicine focus on the early and goal-directed administration of intravascular fluid followed by vasoactive medication infusions for persistent and fluid-refractory shock. However, accumulating adult and pediatric data suggest that excessive fluid administration is associated with worse patient outcomes and even increased risk of death. The optimal amount of intravascular fluid required in early pediatric septic shock resuscitation prior to the initiation of vasoactive support remains unanswered. METHODS/DESIGN The SQUEEZE Pilot Trial is a pragmatic, two-arm, parallel-group, open-label, prospective pilot randomized controlled trial. Participants are children aged 29 days to under 18 years with suspected or confirmed septic shock and a need for ongoing resuscitation. Eligible participants are enrolled under an exception to consent process and randomly assigned via concealed allocation to either the Usual Care (control) or Fluid Sparing (intervention) resuscitation strategy. The primary objective of this pilot trial is to determine feasibility, based on the ability to enroll participants and to adhere to the study protocol. The primary outcome measure by which success will be determined is participant enrollment rate ("pass" defined as at least two participants/site/month, recognizing that enrollment may be slower during the run-in phase). Secondary objectives include assessing (1) appropriateness of eligibility criteria, and (2) completeness of clinical outcomes to inform the endpoints for the planned multisite trial. To support the nested translational study, SQUEEZE-D, we will also evaluate the feasibility of describing cell-free DNA (a procoagulant molecule with prognostic utility) in blood samples obtained from children enrolled into the SQUEEZE Pilot Trial at baseline and at 24 h. DISCUSSION The optimal degree of fluid resuscitation and the timing of initiation of vasoactive support in order to achieve recommended therapeutic targets in children with septic shock remains unanswered. No prospective study to date has examined this important question for children in developed countries including Canada. Recruitment for the SQUEEZE Pilot Trial opened on 6 January 2014. Findings will inform the feasibility of the planned multicenter trial to answer our overall research question. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT01973907 , registered on 23 October 2013.
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Affiliation(s)
- Melissa J. Parker
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children’s Hospital and McMaster University, HSC 3E-20,1280 Main Street West, Hamilton, ON L8S 4K1 Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Division of Emergency Medicine, Department of Pediatrics, the Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Lehana Thabane
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children’s Hospital and McMaster University, HSC 3E-20,1280 Main Street West, Hamilton, ON L8S 4K1 Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Department of Anesthesia, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Biostatistics Unit,/FSORC, St Joseph’s Healthcare Hamilton, 3rd floor Martha Wing, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
| | - Alison Fox-Robichaud
- Department of Medicine, McMaster University, DBRI, Rm C5–106 and 107, 237 Barton Street East, Hamilton, ON L8L 2X2 Canada
| | - Patricia Liaw
- Department of Medicine, McMaster University, DBRI, Rm C5–106 and 107, 237 Barton Street East, Hamilton, ON L8L 2X2 Canada
| | - Karen Choong
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children’s Hospital and McMaster University, HSC 3E-20,1280 Main Street West, Hamilton, ON L8S 4K1 Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
| | - For the Canadian Critical Care Trials Group and the Canadian Critical Care Translational Biology Group
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children’s Hospital and McMaster University, HSC 3E-20,1280 Main Street West, Hamilton, ON L8S 4K1 Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Division of Emergency Medicine, Department of Pediatrics, the Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- Department of Anesthesia, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Biostatistics Unit,/FSORC, St Joseph’s Healthcare Hamilton, 3rd floor Martha Wing, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
- Department of Medicine, McMaster University, DBRI, Rm C5–106 and 107, 237 Barton Street East, Hamilton, ON L8L 2X2 Canada
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