1
|
François B, Lambden S, Fivez T, Gibot S, Derive M, Grouin JM, Salcedo-Magguilli M, Lemarié J, De Schryver N, Jalkanen V, Hicheur T, Garaud JJ, Cuvier V, Ferrer R, Bestle M, Pettilä V, Mira JP, Bouisse C, Mercier E, Vermassen J, Huberlant V, Vinatier I, Anguel N, Levy M, Laterre PF. Prospective evaluation of the efficacy, safety, and optimal biomarker enrichment strategy for nangibotide, a TREM-1 inhibitor, in patients with septic shock (ASTONISH): a double-blind, randomised, controlled, phase 2b trial. Lancet Respir Med 2023; 11:894-904. [PMID: 37269870 DOI: 10.1016/s2213-2600(23)00158-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Activation of the triggering receptor expressed on myeloid cells-1 (TREM-1) pathway is associated with septic shock outcomes. Data suggest that modulation of this pathway in patients with activated TREM-1 might improve survival. Soluble TREM-1 (sTREM-1), a potential mechanism-based biomarker, might facilitate enrichment of patient selection in clinical trials of nangibotide, a TREM-1 modulator. In this phase 2b trial, we aimed to confirm the hypothesis that TREM1 inhibition might improve outcomes in patients with septic shock. METHODS This double-blind, randomised, placebo-controlled, phase 2b trial assessed the efficacy and safety of two different doses of nangibotide compared with placebo, and aimed to identify the optimum treatment population, in patients across 42 hospitals with medical, surgical, or mixed intensive care units (ICUs) in seven countries. Non-COVID-19 patients (18-85 years) meeting the standard definition of septic shock, with documented or suspected infection (lung, abdominal, or urinary [in patients ≥65 years]), were eligible within 24 h of vasopressor initiation for the treatment of septic shock. Patients were randomly assigned in a 1:1:1 ratio to intravenous nangibotide 0·3 mg/kg per h (low-dose group), nangibotide 1·0 mg/kg per h (high-dose group), or matched placebo, using a computer-generated block randomisation scheme (block size 3). Patients and investigators were masked to treatment allocation. Patients were grouped according to sTREM-1 concentrations at baseline (established from sepsis observational studies and from phase 2a change to data) into high sTREM-1 (≥ 400 pg/mL). The primary outcome was the mean difference in total Sequential Organ Failure Assessment (SOFA) score from baseline to day 5 in the low-dose and high-dose groups compared with placebo, measured in the predefined high sTREM-1 (≥ 400 pg/mL) population and in the overall modified intention-to-treat population. Secondary endpoints included all-cause 28-day mortality, safety, pharmacokinetics, and evaluation of the relationship between TREM-1 activation and treatment response. This study is registered with EudraCT, 2018-004827-36, and Clinicaltrials.gov, NCT04055909. FINDINGS Between Nov 14, 2019, and April 11, 2022, of 402 patients screened, 355 were included in the main analysis (116 in the placebo group, 118 in the low-dose group, and 121 in the high-dose group). In the preliminary high sTREM-1 population (total 253 [71%] of 355; placebo 75 [65%] of 116; low-dose 90 [76%] of 118; high-dose 88 [73%] of 121), the mean difference in SOFA score from baseline to day 5 was 0·21 (95% CI -1·45 to 1·87, p=0·80) in the low-dose group and 1·39 (-0·28 to 3·06, p=0·104) in the high-dose group versus placebo. In the overall population, the difference in SOFA score from baseline to day 5 between the placebo group and low-dose group was 0·20 (-1·09 to 1·50; p=0·76),and between the placebo group and the high-dose group was 1·06 (-0·23 to 2·35, p=0·108). In the predefined high sTREM-1 cutoff population, 23 (31%) patients in the placebo group, 35 (39%) in the low-dose group, and 25 (28%) in the high-dose group had died by day 28. In the overall population, 29 (25%) patients in the placebo, 38 (32%) in the low-dose, and 30 (25%) in the high-dose group had died by day 28. The number of treatment-emergent adverse events (111 [96%] patients in the placebo group, 113 [96%] in the low-dose group, and 115 [95%] in the high-dose group) and serious treatment-emergent adverse events (28 [24%], 26 [22%], and 31 [26%]) was similar between all three groups. High-dose nangibotide led to a clinically relevant improvement in SOFA score (of two points or more) from baseline to day 5 over placebo in those with higher cutoff concentrations (≥532 pg/mL) of sTREM-1 at baseline. Low dose nangibotide displayed a similar pattern with lower magnitude of effect across all cutoff values. INTERPRETATION This trial did not achieve the primary outcome of improvement in SOFA score at the predefined sTREM-1 value. Future studies are needed to confirm the benefit of nangibotide at higher concentrations of TREM-1 activation. FUNDING Inotrem.
Collapse
Affiliation(s)
- Bruno François
- Medical-Surgical ICU Department and Inserm CIC1435 & UMR1092, CRICS-TRIGGERSEP Network, CHU Limoges, Limoges, France.
| | - Simon Lambden
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK; Inotrem, Paris, France
| | - Tom Fivez
- Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Sebastien Gibot
- Intensive Care Unit, Centre Hospitalier Regional Universitaire, Nancy, France
| | | | - Jean-Marie Grouin
- Statistics Department, Université de Rouen, Mont Saint-Aignan, France
| | | | | | | | - Ville Jalkanen
- Tampere University Hospital, Intensive Care Unit, Tampere, Finland
| | | | | | | | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron, SODIR Research Group, Vall d'Hebron Institut de Recerca, Spain; Paseig de la Vall d'Hebron, Barcelona, Spain
| | - Morten Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Denmark; Department of Clinical Medicine, University of Copenhagen, Hilleroed, Denmark
| | - Ville Pettilä
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jean-Paul Mira
- Groupe Hospitalier Cochin St Vincent de Paul La Roche Guyon, Paris, France
| | - Camille Bouisse
- Centre Hospitalier de Bourg-en-Bresse, Bourg-en-Bresse, France
| | | | | | | | - Isabelle Vinatier
- Centre Hospitalier Départemental de Vendée, La Roche-sur-Yon, France
| | | | - Mitchell Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | | |
Collapse
|
2
|
Pickkers P, Angus DC, Arend J, Bellomo R, van den Berg E, Bernholz J, Bestle M, Broglio K, Carlsen J, Doig CJ, Ferrer R, Joannidis M, Francois B, Doi K, Kellum JA, Laterre PF, Liu K, Mehta RL, Murray PT, Ostermann M, Pettilä V, Richards S, Young P, Zarbock A, Kjølbye AL. Study protocol of a randomised, double-blind, placebo-controlled, two-arm parallel-group, multi-centre phase 3 pivotal trial to investigate the efficacy and safety of recombinant human alkaline phosphatase for treatment of patients with sepsis-associated acute kidney injury. BMJ Open 2023; 13:e065613. [PMID: 37012016 PMCID: PMC10083765 DOI: 10.1136/bmjopen-2022-065613] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
INTRODUCTION Sepsis, the leading cause of acute kidney injury (AKI), is associated with a high morbidity and mortality. Alkaline phosphatase (ALP) is an endogenous detoxifying enzyme. A recombinant human ALP compound, ilofotase alfa, showed no safety or tolerability concerns in a phase 2 trial. Renal function improvement over 28 days was significantly greater in the ilofotase alfa group. Moreover, a significant relative reduction in 28-day all-cause mortality of >40% was observed. A follow-up trial has been designed to confirm these findings. METHODS AND ANALYSIS This is a phase 3, global, multi-centre, randomised, double-blind, placebo-controlled, sequential design trial in which patients are randomly assigned to either placebo or 1.6 mg/kg ilofotase alfa. Randomisation is stratified by baseline modified Sequential Organ Failure Assessment (mSOFA) score and trial site. The primary objective is to confirm the survival benefit with ilofotase alfa by demonstrating a reduction in 28-day all-cause mortality in patients with sepsis-associated AKI requiring vasopressors. A maximum of 1400 patients will be enrolled at ∼120 sites in Europe, North America, Japan, Australia and New Zealand. Up to four interim analyses will take place. Based on predefined decision rules, the trial may be stopped early for futility or for effectiveness. In addition, patients with COVID-19 disease and patients with 'moderate to severe' chronic kidney disease are analysed as 2 separate cohorts of 100 patients each. An independent Data Monitoring Committee evaluates safety data at prespecified intervals throughout the trial. ETHICS AND DISSEMINATION The trial is approved by relevant institutional review boards/independent ethics committees and is conducted in accordance with the ethical principles of the Declaration of Helsinki, guidelines of Good Clinical Practice, Code of Federal Regulations and all other applicable regulations. Results of this study will determine the potential of ilofotase alfa to reduce mortality in critically ill patients with sepsis-associated AKI and will be published in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER EudraCT CT Number 2019-0046265-24. US IND Number 117 605 Pre-results. CLINICALTRIALS gov number: NCT04411472.
Collapse
Affiliation(s)
- Peter Pickkers
- Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Austin Hospital, Melbourne, Victoria, Australia
| | | | | | - Morten Bestle
- Department of Anaesthesiology and Intensive care, Nordsjaellands Hospital, Hillerod, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Christopher J Doig
- Department of Critical Care Medicine, University of Calgary Medical Centre, Calgary, Alberta, Canada
| | - Ricard Ferrer
- Intensive Care Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Bruno Francois
- ICU and Inserm C1C, University of Limoges, Limoges, France
| | - Kent Doi
- Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Kathleen Liu
- Divisions of Critical Care Medicine and Nephrology, Departments of Anesthesia and Medicine, University of California San Fransisco, San Francisco, California, USA
| | - Ravindra L Mehta
- Department of Medicine, University of California, San Diego, California, USA
| | | | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, Helsingin Yliopisto Laaketieteellinen tiedekunta, Helsinki, Finland
| | | | - Paul Young
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, Universität Münster, Münster, Germany
| | | |
Collapse
|
3
|
Andersen-Ranberg NC, Poulsen LM, Perner A, Hästbacka J, Morgan M, Citerio G, Collet MO, Weber SO, Andreasen AS, Bestle M, Uslu B, Pedersen HS, Nielsen LG, Damgaard K, Jensen TB, Sommer T, Dey N, Mathiesen O, Granholm A. Haloperidol vs. placebo for the treatment of delirium in ICU patients: a pre-planned, secondary Bayesian analysis of the AID–ICU trial. Intensive Care Med 2023; 49:411-420. [PMID: 36971791 DOI: 10.1007/s00134-023-07024-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/28/2023] [Indexed: 03/28/2023]
Abstract
PURPOSE The AID-ICU trial was a randomised, blinded, placebo-controlled trial investigating effects of haloperidol versus placebo in acutely admitted, adult patients admitted in intensive care unit (ICU) with delirium. This pre-planned Bayesian analysis facilitates probabilistic interpretation of the AID-ICU trial results. METHODS We used adjusted Bayesian linear and logistic regression models with weakly informative priors to analyse all primary and secondary outcomes reported up to day 90, and with sensitivity analyses using other priors. The probabilities for any benefit/harm, clinically important benefit/harm, and no clinically important differences with haloperidol treatment according to pre-defined thresholds are presented for all outcomes. RESULTS The mean difference for days alive and out of hospital to day 90 (primary outcome) was 2.9 days (95% credible interval (CrI) - 1.1 to 6.9) with probabilities of 92% for any benefit and 82% for clinically important benefit. The risk difference for mortality was - 6.8 percentage points (95% CrI - 12.8 to - 0.8) with probabilities of 99% for any benefit and 94% for clinically important benefit. The adjusted risk difference for serious adverse reactions was 0.3 percentage points (95% CrI - 1.3 to 1.9) with 98% probability of no clinically important difference. Results were consistent across sensitivity analyses using different priors, with more than 83% probability of benefit and less than 17% probability of harm with haloperidol treatment. CONCLUSIONS We found high probabilities of benefits and low probabilities of harm with haloperidol treatment compared with placebo in acutely admitted, adult ICU patients with delirium for the primary and most secondary outcomes.
Collapse
|
4
|
Anthon CT, Pène F, Perner A, Azoulay E, Puxty K, Van De Louw A, Barret‐Due A, Chawla S, Castro P, Povoa P, Coelho L, Metaxa V, Munshi L, Kochanek M, Liebregts T, Kander T, Hästbacka J, Møller MH, Russell L, Anthon CT, Hildebrandt T, Vogelius MK, Clausen N, Bestle M, Lorentzen K, Nielsen LB, Andreasen JB, Hvas CL, Juhl CS, Lundqvist L, Lindquist E, Barret‐Due A, Bådstøløkken PM, Holten AR, Kvåle R, Strand K, Klepstad P, Hästbacka J, Jalkanen V, Reinikainen M, Péju E, Marin N, Pène F, Vimpere D, Menat S, Voiriot G, Schmidt J, Dufranc E, Uhel F, Lafarge A, Missri L, Ait‐Oufella H, Canet E, Metexa V, Puxty K, Wright C, Castro P, Costa C, Coelho L, Povoa P, Paulino MC, Graça C, Torres JCS, Chawla S, Voigt L, Van de Louw A, Munshi L, Lueck C, Kochanek M, Liebgrets T. Platelet transfusions and thrombocytopenia in intensive care units: protocol for an international inception cohort study (PLOT‐ICU). Acta Anaesthesiol Scand 2022; 66:1146-1155. [PMID: 36054145 PMCID: PMC9542787 DOI: 10.1111/aas.14124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022]
Abstract
Introduction Thrombocytopenia is frequent in intensive care unit (ICU) patients and has been associated with worse outcome. Platelet transfusions are often used in the management of ICU patients with severe thrombocytopenia. However, the reported frequencies of thrombocytopenia and platelet transfusion practices in the ICU vary considerably. Therefore, we aim to provide contemporary epidemiological data on thrombocytopenia and platelet transfusion practices in the ICU. Methods We will conduct an international inception cohort, including at least 1000 acutely admitted adult ICU patients. Routinely available data will be collected at baseline (ICU admission), and daily during ICU stay up to a maximum of 90 days. The primary outcome will be the number of patients with thrombocytopenia (a recorded platelet count < 150 × 109/L) at baseline and/or during ICU stay. Secondary outcomes include mortality, days alive and out of hospital, days alive without life‐support, the number of patients with at least one bleeding episode, at least one thromboembolic event and at least one platelet transfusion in the ICU, the number of platelet transfusions and the indications for transfusion. The primary and secondary outcomes will be presented descriptively. In addition, we will assess risk factors for developing thrombocytopenia during ICU stay and the association between thrombocytopenia at baseline and 90‐day mortality using logistic regression analyses. Conclusion The outlined international PLOT‐ICU cohort study will provide contemporary epidemiological data on the burden and clinical significance of thrombocytopenia in adult ICU patients and describe the current platelet transfusion practice.
Collapse
Affiliation(s)
- Carl Thomas Anthon
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Frédéric Pène
- Médecine Intensive & Réanimation, Hôpital Cochin, Assistance Publique – Hôpitaux de Paris Université Paris Cité Paris France
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Hôpital Saint‐Louis, Assistance Publique – Hôpitaux de Paris Université Paris Cité Paris France
| | - Kathryn Puxty
- Department of Intensive Care Glasgow Royal Infirmary Glasgow United Kingdom
| | - Andry Van De Louw
- Division of Pulmonary and Critical Care Penn State University College of Medicine Hershey PA USA
| | - Andreas Barret‐Due
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Rikshospitalet Oslo University Hospital Oslo Norway
| | - Sanjay Chawla
- Critical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine Memorial Sloan Kettering Cancer Center New York NY USA
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic of Barcelona; IDIBAPS; University of Barcelona Barcelona Spain
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal and NOVA Medical School New University of Lisbon Lisbon Portugal
| | - Luis Coelho
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal and NOVA Medical School New University of Lisbon Lisbon Portugal
| | - Victoria Metaxa
- Department of Critical Care King's College Hospital NHS Foundation Trust London United Kingdom
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network University of Toronto Toronto Ontario Canada
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne University of Cologne Cologne Germany
| | - Tobias Liebregts
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen University of Duisburg‐Essen Essen Germany
| | - Thomas Kander
- Department of Intensive and Perioperative Care, Skåne University Hospital, Sweden and Department of Clinical Sciences Lund University Sweden
| | - Johanna Hästbacka
- Department of Perioperative, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Lene Russell
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Johansson PI, Bestle M, Søe-Jensen P, Kristiansen KT, Stensballe J, Clausen NE, Perner A. The effect of prostacyclin (Iloprost) infusion at a dose of 1 ng/kg/min for 72 hours compared to placebo in mechanically ventilated patients with COVID-19: A structured summary of a study protocol for a randomized controlled trial. Trials 2020; 21:746. [PMID: 32847626 PMCID: PMC7447606 DOI: 10.1186/s13063-020-04696-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES To investigate the effect of continuous infusion of the potential endothelial cytoprotective agent prostacyclin (Iloprost) 1 ng/kg/min vs. placebo for 72 hours on pulmonary endotheliopathy in mechanically ventilated COVID-19 patients. TRIAL DESIGN A multicenter, randomized (1:1, active: placebo), blinded, parallel group exploratory trial PARTICIPANTS: Inclusion criteria are: Adult patients (>18 years); Confirmed COVID-19 infection; Need for mechanical interventions; Endothelial biomarker soluble thrombomodulin >4ng/ml. EXCLUSION CRITERIA Withdrawal from active therapy; Pregnancy (non-pregnancy confirmed by patient being postmenopausal (age 60 or above) or having a negative urine- or plasma-hCG); Known hypersensitivity to iloprost or to any of the other ingredients; Previously included in this trial or a prostacyclin trial within 30 days; Consent cannot be obtained; Life-threatening bleeding defined by the treating physician; Known severe heart failure (NYHA class IV); Suspected acute coronary syndrome The study is conducted at five intensive care units in the Capital Region of Denmark at Rigshospitalet, Herlev Hospital, Hvidovre Hospital, Bispebjerg Hospital, Nordsjællands Hospital. INTERVENTION AND COMPARATOR The patients are randomized to 72-hours continuous infusion of either prostacyclin (Iloprost/Ilomedin) at a dose of 1 ng/kg/min or Placebo (normal saline). MAIN OUTCOMES Primary endpoint: Days alive without mechanical ventilation in the intensive care units within 28 days RANDOMISATION: The randomisation sequence is performed in permuted blocks of variable sizes stratified for trial site using centralised, concealed allocation. The randomisation sequence is generated 1:1 (active/placebo) using the online randomisation software 'Sealed Envelope' ( https://www.sealedenvelope.com/ ). Once generated the randomisation sequence is formatted and uploaded into Research Electronic Data Capture system (REDCap) to facilitate centralised, web-based allocation according to local written instruction. BLINDING (MASKING) The following are blinded: all clinicians, patients, investigators, and those assessing the outcomes including the statisticians. NUMBERS TO BE RANDOMISED (SAMPLE SIZE) Forty patients are planned to be randomized to each group, with a total sample size of 80 patients. TRIAL STATUS Protocol version 1.4 dated May 25, 2020. Recruitment is ongoing. The recruitment was started June 15, 2020 and the anticipated finish of recruitment is February 28, 2021 with 90 days follow up hereafter. TRIAL REGISTRATION Trial registration at clinicaltrialregisters.eu; EudraCT no. 2020-001296-33 on 3 April 2020 and at ClinicalTrials.gov Identifier: NCT04420741 on 9 June 2020 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1).In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.
Collapse
Affiliation(s)
| | - Morten Bestle
- Department of Intensive Care, Nordsjællands Hospital, Hillerød, Denmark
| | | | | | - Jakob Stensballe
- Department of Anaesthesiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Anders Perner
- Department of Intensive Care 4131, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
6
|
Jensen JUS, Peters L, Itenov TS, Bestle M, Thormar KM, Mohr TT, Lundgren B, Grarup J, Lundgren JD. Biomarker-assisted identification of sepsis-related acute liver impairment: a frequent and deadly condition in critically ill patients. Clin Chem Lab Med 2020; 57:1422-1431. [PMID: 30951497 DOI: 10.1515/cclm-2018-1350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/04/2019] [Indexed: 01/30/2023]
Abstract
Background The prognostic impact of mild/moderate liver impairment among critically ill patients is not known. We aimed to determine whether acute liver impairment, as measured by several biomarkers, (i) is frequent, (ii) influences prognosis and (iii) to determine whether such an effect is specific for infected critically ill patients. Methods A biomarker and clinical cohort study based on a randomized controlled trial. All-cause mortality was the primary endpoint. Biomarkers hyaluronic acid (HA), bilirubin, albumin, alkaline phosphatase and the international normalized ratio (INR) were determined. Multivariable statistics were applied to estimate risk increase according to liver biomarker increase at baseline and the model was adjusted for age, APACHE II, severe sepsis/septic shock vs. milder infection, chronic alcohol abuse Charlson's co-morbidity index, cancer disease, surgical or medical patient, body mass index, sex, estimated glomerular filtration rate, mechanical ventilation and the other biomarkers. Time-to-event graphs were used. The patients were critically ill patients (n = 1096) from nine mixed medical/surgical intensive care units without known hepatobiliary disease. Results HA levels differed between infected patients (median 210.8 ng/mL [IQR: 93.2-556.6]) vs. the non-infected (median 56.8 ng/mL [IQR: 31.9-116.8], p < 0.001). Serum HA quartiles 2, 3 and 4 were independent predictors of 90-day all-cause mortality for the entire population (infected and non-infected). However, the signal was driven by the infected patients (positive interaction test, no signal in non-infected patients). Among infected patients, HA quartiles corresponded directly to the 90-day risk of dying: 1st quartile: 57/192 = 29.7%, 2nd quartile: 84/194 = 43.3%, 3rd quartile: 90/193 = 46.6%, 4th quartile: 101/192 = 52.3 %, p for trend: <0.0001. This finding was confirmed in adjusted analyses: hazard ratio vs. 1st quartile: 2nd quartile: 1.3 [0.9-1.8], p = 0.14, 3rd quartile: 1.5 [1.1-2.2], p = 0.02, 4th quartile: 1.9 [1.3-2.6], p < 0.0001). High bilirubin was also an independent predictor of mortality. Conclusions Among infected critically ill patients, subtle liver impairment, (elevated HA and bilirubin), was associated with a progressive and highly increased risk of death for the patient; this was robust to adjustment for other predictors of mortality. HA can identify patients at high risk.
Collapse
Affiliation(s)
- Jens-Ulrik Stæhr Jensen
- CHIP & PERSIMUNE, Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen and University of Copenhagen, Copenhagen, Denmark.,Department of Internal Medicine C, Respiratory Medicine Section, Copenhagen University Hospital, Herlev-Gentofte, Denmark
| | - Lars Peters
- CHIP & PERSIMUNE, Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen and University of Copenhagen, Copenhagen, Denmark
| | - Theis S Itenov
- CHIP & PERSIMUNE, Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen and University of Copenhagen, Copenhagen, Denmark.,Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Hillerød, Denmark
| | - Morten Bestle
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Hillerød, Denmark.,Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Glostrup, Denmark
| | - Katrin M Thormar
- Department of Anesthesia and Intensive Care, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Gentofte, Denmark
| | - Thomas T Mohr
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Glostrup, Denmark.,Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Gentofte, Denmark
| | - Bettina Lundgren
- Diagnostic Center, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Jesper Grarup
- CHIP & PERSIMUNE, Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen and University of Copenhagen, Copenhagen, Denmark
| | - Jens D Lundgren
- CHIP & PERSIMUNE, Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen and University of Copenhagen, Copenhagen, Denmark
| | | |
Collapse
|
7
|
Nielsen PB, Schultz M, Langkjaer CS, Kodal AM, Pedersen NE, Petersen JA, Lange T, Arvig MD, Meyhoff CS, Bestle M, Hølge-Hazelton B, Bunkenborg G, Lippert A, Andersen O, Rasmussen LS, Iversen KK. Adjusting Early Warning Score by clinical assessment: a study protocol for a Danish cluster-randomised, multicentre study of an Individual Early Warning Score (I-EWS). BMJ Open 2020; 10:e033676. [PMID: 31915173 PMCID: PMC6955532 DOI: 10.1136/bmjopen-2019-033676] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/13/2019] [Accepted: 11/27/2019] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Track and trigger systems (TTSs) based on vital signs are implemented in hospitals worldwide to identify patients with clinical deterioration. TTSs may provide prognostic information but do not actively include clinical assessment, and their impact on severe adverse events remain uncertain. The demand for prospective, multicentre studies to demonstrate the effectiveness of TTSs has grown the last decade. Individual Early Warning Score (I-EWS) is a newly developed TTS with an aggregated score based on vital signs that can be adjusted according to the clinical assessment of the patient. The objective is to compare I-EWS with the existing National Early Warning Score (NEWS) algorithm regarding clinical outcomes and use of resources. METHOD AND ANALYSIS In a prospective, multicentre, cluster-randomised, crossover, non-inferiority study. Eight hospitals are randomised to use either NEWS in combination with the Capital Region of Denmark NEWS Override System (CROS) or implement I-EWS for 6.5 months, followed by a crossover. Based on their clinical assessment, the nursing staff can adjust the aggregated score with a maximum of -4 or +6 points. We expect to include 150 000 unique patients. The primary endpoint is all-cause mortality at 30 days. Coprimary endpoint is the average number of times per day a patient is NEWS/I-EWS-scored, and secondary outcomes are all-cause mortality at 48 hours and at 7 days as well as length of stay. ETHICS AND DISSEMINATION The study was presented for the Regional Ethics committee who decided that no formal approval was needed according to Danish law (J.no. 1701733). The I-EWS study is a large prospective, randomised multicentre study that investigates the effect of integrating a clinical assessment performed by the nursing staff in a TTS, in a head-to-head comparison with the internationally used NEWS with the opportunity to use CROS. TRIAL REGISTRATION NUMBER NCT03690128.
Collapse
Affiliation(s)
- Pernille B Nielsen
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Martin Schultz
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | | | - Anne Marie Kodal
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerod, Denmark
| | - Niels Egholm Pedersen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John Asger Petersen
- Department of Day Surgery, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Theis Lange
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
- Center for Statistical Science, Peking University, Beijing, China
| | - Michael Dan Arvig
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Sahlholt Meyhoff
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Morten Bestle
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerod, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Bibi Hølge-Hazelton
- Research Support Unit, Zealand University Hospital Roskilde, Roskilde, Denmark
- Department of Regional Studies, University of Southern Denmark, Odense, Denmark
| | - Gitte Bunkenborg
- Department of Anesthesiology, Holbaek Hospital, Holbaek, Denmark
| | - Anne Lippert
- Copenhagen Academy for Medical Education and Simulation, Herlev, Denmark
| | - Ove Andersen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Karmark Iversen
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
8
|
Andersen‐Ranberg NC, Poulsen LM, Perner A, Wetterslev J, Estrup S, Lange T, Ebdrup BH, Hästbacka J, Morgan MP, Citerio G, Zafrani L, Caballero J, Oxenbøll-Collet M, Weber S, Andreasen AS, Bestle M, Pedersen HBS, Hildebrandt T, Thee C, Jensen TB, Dey N, Nielsen LG, Mathiesen O. Agents intervening against delirium in the intensive care unit (AID-ICU) - Protocol for a randomised placebo-controlled trial of haloperidol in patients with delirium in the ICU. Acta Anaesthesiol Scand 2019; 63:1426-1433. [PMID: 31350916 DOI: 10.1111/aas.13453] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 07/21/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Delirium among patients in the intensive care unit (ICU) is a common condition associated with increased morbidity and mortality. Haloperidol is the most frequently used pharmacologic intervention, but its use is not supported by firm evidence. Therefore, we are conducting Agents Intervening against Delirium in the Intensive Care Unit (AID-ICU) trial to assess the benefits and harms of haloperidol for the treatment of ICU-acquired delirium. METHODS AID-ICU is an investigator-initiated, pragmatic, international, randomised, blinded, parallel-group, trial allocating adult ICU patients with manifest delirium 1:1 to haloperidol or placebo. Trial participants will receive intravenous 2.5 mg haloperidol three times daily or matching placebo (isotonic saline 0.9%) if they are delirious. If needed, a maximum of 20 mg/daily haloperidol/placebo is given. An escape protocol, not including haloperidol, is part of the trial protocol. The primary outcome is days alive out of the hospital within 90 days post-randomisation. Secondary outcomes are number of days without delirium or coma, serious adverse reactions to haloperidol, usage of escape medication, number of days alive without mechanical ventilation; mortality, health-related quality-of-life and cognitive function at 1-year follow-up. A sample size of 1000 patients is required to detect a 7-day improvement or worsening of the mean days alive out of the hospital, type 1 error risk of 5% and power 90%. PERSPECTIVE The AID-ICU trial is based on gold standard methodology applied to a large sample of clinically representative patients and will provide pivotal high-quality data on the benefits and harms of haloperidol for the treatment ICU-acquired delirium.
Collapse
Affiliation(s)
- Nina C. Andersen‐Ranberg
- Department of Anaesthesiology and Intensive Care Medicine Zealand University Hospital Koege Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Lone M. Poulsen
- Department of Anaesthesiology and Intensive Care Medicine Zealand University Hospital Koege Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Anders Perner
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Copenhagen Trial Unit (CTU), Department 7812, Centre for Clinical Intervention Research Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Stine Estrup
- Department of Anaesthesiology and Intensive Care Medicine Zealand University Hospital Koege Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Theis Lange
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Public Health, Section of Biostatistics Copenhagen University Copenhagen Denmark
| | - Bjørn H. Ebdrup
- Centre for Neuropsychiatric Schizophrenia Research (CNSR) & Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS) Mental Health Centre Glostrup, University of Copenhagen Glostrup Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Johanna Hästbacka
- Department of Anaesthesiology Helsinki University Hospital Helsinki Finland
| | | | | | - Lara Zafrani
- Intensive Care Unit AP HP, Saint Louis University Hospital Paris France
| | - Jesús Caballero
- Hospital Universitari Arnau de Vilanova de Lleida, IRBLLeida Departament de Medicina‐Universitat Autònoma de Barcelona‐UABBarcelona Spain
| | - Marie Oxenbøll-Collet
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Sven‐Olaf Weber
- General Intensive Care Unit Aalborg University Hospital Aalborg Denmark
| | | | - Morten Bestle
- Department of Anaesthesiology and Intensive Care Nordsjællands Hospital Hillerod Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Helle B. S. Pedersen
- Department of Anaesthesiology and Intensive Care Nykøbing Falster Hospital Nykobing Denmark
| | - Thomas Hildebrandt
- Department of Anaesthesiology and Intensive Care Medicine Zealand University Hospital Roskilde Denmark
| | - Carsten Thee
- Department of Anaesthesiology and Intensive Care Medicine Sønderjylland Hospital Aabenraa Denmark
| | - Troels B. Jensen
- Department of Anaesthesiology and Intensive Care Medicine Hospital Unit West Jutland Herning Denmark
| | - Nilanjan Dey
- Department of Anaesthesiology and Intensive Care Medicine Hospital Unit West Jutland Herning Denmark
| | - Louise G. Nielsen
- Department of Anesthesia and Intensive Care Medicine Odense University Hospital, University of Southern Denmark Odense Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology and Intensive Care Medicine Zealand University Hospital Koege Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| |
Collapse
|
9
|
Marker S, Krag M, Perner A, Wetterslev J, Lange T, Wise MP, Borthwick M, Bendel S, Keus F, Guttormsen AB, Schefold JC, Rasmussen BS, Elkmann T, Bestle M, Arenkiel B, Laake JH, Kamper MK, Lång M, Pawlowicz‐Dworzanska MB, Karlsson S, Liisanantti J, Dey N, Knudsen H, Granholm A, Møller MH. Pantoprazole in ICU patients at risk for gastrointestinal bleeding-1-year mortality in the SUP-ICU trial. Acta Anaesthesiol Scand 2019; 63:1184-1190. [PMID: 31282567 DOI: 10.1111/aas.13436] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/14/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND The long-term effects of stress ulcer prophylaxis with pantoprazole are unknown in ICU patients. We report 1-year mortality outcome in the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial. METHODS In the SUP-ICU trial, acutely admitted adult ICU patients at risk of gastrointestinal bleeding were randomised to intravenous pantoprazole 40 mg vs placebo (saline) once daily during their ICU stay. We assessed mortality at 1 year and did sensitivity analyses according to the trial protocol and statistical analysis plan. RESULTS A total of 3261 of the 3291 patients with available data (99.1%) were followed up at 1 year after randomisation; 1635 were allocated to pantoprazole and 1626 to placebo. At 1 year after randomisation, 610 of 1635 patients (37.3%) had died in the pantoprazole group as compared with 601 of 1626 (37.0%) in the placebo group (relative risk, 1.01; 95% confidence interval 0.92-1.10). The results were consistent in the sensitivity analysis adjusted for baseline risk factors and in those of the per-protocol population. We did not observe heterogeneity in the effect of pantoprazole vs placebo on 1-year mortality in the predefined subgroups, that is, patients with and without shock, mechanical ventilation, liver disease, coagulopathy, high disease severity (SAPS II > 53) or in medical vs surgical ICU patients. CONCLUSION We did not observe a difference in 1-year mortality among acutely admitted adult ICU patients with risk factors for gastrointestinal bleeding allocated to stress ulcer prophylaxis with pantoprazole or placebo during the ICU stay. (The SUP-ICU trial was funded by Innovation Fund Denmark and others; ClinicalTrials.gov number, NCT02467621).
Collapse
Affiliation(s)
- Søren Marker
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Mette Krag
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care (CRIC) Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Theis Lange
- Section of Biostatistics University of Copenhagen Copenhagen Denmark
- Center for Statistical Science Peking University Beijing China
| | - Matt P. Wise
- Department of Adult Critical Care University Hospital of Wales Cardiff UK
| | - Mark Borthwick
- Pharmacy Department Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - Stepani Bendel
- Department of Intensive Care Medicine Kuopio University Hospital Kuopio Finland
| | - Frederik Keus
- Department of Critical Care University Medical Center Groningen, University of Groningen Groningen The Netherlands
| | - Anne Berit Guttormsen
- Department of Anaesthesia and Intensive Care Haukeland University Hospital Bergen Norway
- Department of Clinical Medicine UiB Bergen Norway
| | - Joerg C. Schefold
- Department of Intensive Care Medicine Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Bodil S. Rasmussen
- Centre for Research in Intensive Care (CRIC) Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
| | - Thomas Elkmann
- Department of Intensive Care Aarhus University Hospital Aarhus Denmark
| | - Morten Bestle
- Centre for Research in Intensive Care (CRIC) Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Nordsjælland HospitalUniversity of Copenhagen Hillerød Denmark
| | - Bjørn Arenkiel
- Department of Anaesthesia and Intensive Care Holbæk Hospital Holbæk Denmark
| | - Jon H. Laake
- Division of Emergencies and Critical Care, Department of Anaesthesiology, Rikshospitalet Medical Centre Oslo University Hospital Oslo Norway
| | - Maj K. Kamper
- Department of Anaesthesia and Intensive Care Bispebjerg Hospital, University of Copenhagen Copenhagen Denmark
| | - Maarit Lång
- Department of Intensive Care Medicine Kuopio University Hospital Kuopio Finland
| | | | - Sari Karlsson
- Department of Intensive Care Tampere University Hospital Tampere Finland
| | - Janne Liisanantti
- Department of Anaesthesia and Intensive Care Oulu University Hospital Oulu Finland
| | - Nilanjan Dey
- Department of Anaesthesia and Intensive Care Regionshospitalet Holstebro—Hospitalsenheden Vest Holstebro Denmark
| | - Heidi Knudsen
- Department of Anaesthesia and Intensive Care Herlev Hospital, University of Copenhagen Herlev Denmark
| | - Anders Granholm
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | | |
Collapse
|
10
|
Itenov TS, Johansen ME, Bestle M, Thormar K, Hein L, Gyldensted L, Lindhardt A, Christensen H, Estrup S, Pedersen HP, Harmon M, Soni UK, Perez-Protto S, Wesche N, Skram U, Petersen JA, Mohr T, Waldau T, Poulsen LM, Strange D, Juffermans NP, Sessler DI, Tønnesen E, Møller K, Kristensen DK, Cozzi-Lepri A, Lundgren JD, Jensen JU. Induced hypothermia in patients with septic shock and respiratory failure (CASS): a randomised, controlled, open-label trial. Lancet Respir Med 2018; 6:183-192. [PMID: 29325753 PMCID: PMC10928558 DOI: 10.1016/s2213-2600(18)30004-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 11/17/2017] [Accepted: 11/17/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Animal models of serious infection suggest that 24 h of induced hypothermia improves circulatory and respiratory function and reduces mortality. We tested the hypothesis that a reduction of core temperature to 32-34°C attenuates organ dysfunction and reduces mortality in ventilator-dependent patients with septic shock. METHODS In this randomised, controlled, open-label trial, we recruited patients from ten intensive care units (ICUs) in three countries in Europe and North America. Inclusion criteria for patients with severe sepsis or septic shock were a mean arterial pressure of less than 70 mm Hg, mechanical ventilation in an ICU, age at least 50 years, predicted length of stay in the ICU at least 24 h, and recruitment into the study within 6 h of fulfilling inclusion criteria. Exclusion criteria were uncontrolled bleeding, clinically important bleeding disorder, recent open surgery, pregnancy or breastfeeding, or involuntary psychiatric admission. We randomly allocated patients 1:1 (with variable block sizes ranging from four to eight; stratified by predictors of mortality, age, Acute Physiology and Chronic Health Evaluation II score, and study site) to routine thermal management or 24 h of induced hypothermia (target 32-34°C) followed by 48 h of normothermia (36-38°C). The primary endpoint was 30 day all-cause mortality in the modified intention-to-treat population (all randomly allocated patients except those for whom consent was withdrawn or who were discovered to meet an exclusion criterion after randomisation but before receiving the trial intervention). Patients and health-care professionals giving the intervention were not masked to treatment allocation, but assessors of the primary outcome were. This trial is registered with ClinicalTrials.gov, number NCT01455116. FINDINGS Between Nov 1, 2011, and Nov 4, 2016, we screened 5695 patients. After recruitment of 436 of the planned 560 participants, the trial was terminated for futility (220 [50%] randomly allocated to hypothermia and 216 [50%] to routine thermal management). In the hypothermia group, 96 (44·2%) of 217 died within 30 days versus 77 (35·8%) of 215 in the routine thermal management group (difference 8·4% [95% CI -0·8 to 17·6]; relative risk 1·2 [1·0-1·6]; p=0·07]). INTERPRETATION Among patients with septic shock and ventilator-dependent respiratory failure, induced hypothermia does not reduce mortality. Induced hypothermia should not be used in patients with septic shock. FUNDING Trygfonden, Lundbeckfonden, and the Danish National Research Foundation.
Collapse
Affiliation(s)
- Theis Skovsgaard Itenov
- Department of Anesthesia and Intensive Care, Nordsjællands Hospital, Hillerød, Denmark; Centre of Excellence in Immunity and Infection/Centre of Excellence for Personalised Medicine of Infectious Complications in Immune Deficiency, Department of Infectious Diseases, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Maria Egede Johansen
- Centre of Excellence in Immunity and Infection/Centre of Excellence for Personalised Medicine of Infectious Complications in Immune Deficiency, Department of Infectious Diseases, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Morten Bestle
- Department of Anesthesia and Intensive Care, Nordsjællands Hospital, Hillerød, Denmark
| | - Katrin Thormar
- Department of Anesthesia and Intensive Care, Bispebjerg Hospital, Copenhagen, Denmark
| | - Lars Hein
- Department of Anesthesia and Intensive Care, Nordsjællands Hospital, Hillerød, Denmark
| | - Louise Gyldensted
- Department of Anesthesia and Intensive Care, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Anne Lindhardt
- Department of Anesthesia and Intensive Care, Bispebjerg Hospital, Copenhagen, Denmark
| | - Henrik Christensen
- Department of Anesthesia and Intensive Care, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Stine Estrup
- Department of Anesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | | | - Matthew Harmon
- Department of Intensive Care, Academic Medical Center, Amsterdam, Netherlands
| | - Uday Kant Soni
- Department of Anesthesia and Intensive Care, Horsens Hospital, Horsens, Denmark
| | - Silvia Perez-Protto
- Center for Critical Care, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nicolai Wesche
- Department of Anesthesia and Intensive Care, Nordsjællands Hospital, Hillerød, Denmark
| | - Ulrik Skram
- Department of Anesthesia and Intensive Care, Nordsjællands Hospital, Hillerød, Denmark
| | - John Asger Petersen
- Department of Anesthesia and Intensive Care, Bispebjerg Hospital, Copenhagen, Denmark
| | - Thomas Mohr
- Department of Anesthesia and Intensive Care, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Tina Waldau
- Department of Anesthesia and Intensive Care, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Lone Musaeus Poulsen
- Department of Anesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Ditte Strange
- Department of Anesthesia and Intensive Care, Bispebjerg Hospital, Copenhagen, Denmark
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, Amsterdam, Netherlands
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Else Tønnesen
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Dennis Karsten Kristensen
- Centre of Excellence in Immunity and Infection/Centre of Excellence for Personalised Medicine of Infectious Complications in Immune Deficiency, Department of Infectious Diseases, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Alessandro Cozzi-Lepri
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK
| | - Jens D Lundgren
- Centre of Excellence in Immunity and Infection/Centre of Excellence for Personalised Medicine of Infectious Complications in Immune Deficiency, Department of Infectious Diseases, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Jens-Ulrik Jensen
- Centre of Excellence in Immunity and Infection/Centre of Excellence for Personalised Medicine of Infectious Complications in Immune Deficiency, Department of Infectious Diseases, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark; Respiratory Medicine Division, Department of Internal Medicine, Herlev and Gentofte Hospital, Hellerup, Denmark.
| |
Collapse
|
11
|
Itenov TS, Johansen ME, Bestle M, Thormar K, Hein L, Gyldensted L, Lindhardt A, Christensen H, Damby SE, Pedersen HP, Harmon M, Soni UK, Perez-Protto S, Wesche N, Berthelsen RE, Skram U, Petersen A, Mohr T, Waldau T, Poulsen LM, Strange D, Christensen O, Juffermans NP, Sessler D, Tønnesen E, Kristensen D, Cozzi-Lepri A, Lundgren J, Jensen JUS. Induced Hypothermia in Patients with Septic Shock and Ventilator-demanding Respiratory Failure. Open Forum Infect Dis 2017. [PMCID: PMC5631956 DOI: 10.1093/ofid/ofx162.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Animal models of serious infection suggest that 24 hours of induced hypothermia improves circulatory and respiratory characteristics and enhances survival, but whether therapeutic mild hypothermia in such conditions is of clinical benefit remains unknown. We, therefore, tested whether reducing core temperature to 32–34oC in critically ill patients with septic shock and ventilator-demanding respiratory failure improves survival and reduces organ dysfunction. Methods In this multi-national trial, patients with septic shock were enrolled within 6 hours of onset of septic shock and ventilator-demanding respiratory failure and randomized 1:1, stratified by site (target sample = 560), to routine thermal management or 24 hours of induced hypothermia (target 32–34°C) followed by 48 hours of normothermia. Other aspects of care were per routine in each participating center. The primary endpoint was 30-day all-cause mortality. Results At the third ordinary interim analysis, after recruitment of 432 participants, the Data and Safety Monitoring Board recommended the trial be terminated for futility; the conditional power for rejection of the null hypothesis in favor of efficacy was null. In the induced hypothermia group, target temperature was reached within median 3.2 hours [IQR: 2.2, 4.8], and maintained for 24 hours [IQR: 24, 24] (Figure 1). There was no evidence for a difference in 30-day mortality risk in patients randomized to hypothermia (96/217) vs. routine thermal management (77/215): relative risk 1.24 [95% CI: 0.98, 1.56] (Figure 2). At the end of the temperature intervention (72 hours), more patients assigned to hypothermia were in continued shock (vasoactive medication 71% vs. 58%; P = 0.01), and fewer cooled patients had inflammatory control (32% vs. 47% had CRP decline of >30%, P = 0.005). More harm from cooling was seen in patients entering the trial with normal renal function and with normal platelet count (P for interaction < 0.05). Conclusion Among patients with septic shock and ventilator-demanding respiratory failure, induced hypothermia did not improve survival, but adversely affected the duration of shock, and inflammatory control. Induced hypothermia should not routinely be used in patients with septic shock. Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
| | | | - Morten Bestle
- Anesthesia and Intensive Care, North Zealand Hospital, Hillerød, Denmark
| | - Katrin Thormar
- Anesthesia and Intensive Care, Bispebjerg Hospital, Copenhagen NW, Denmark
| | - Lars Hein
- Department of Anesthesia and Intensive Care,, North Zealand Hospital, Hillerød, Denmark
| | - Louise Gyldensted
- Anesthesia and Intensive Care, Herlev & Gentofte Hospital, Hellerup, Denmark
| | - Anne Lindhardt
- Anesthesia and Intensive Care, Bispebjerg Hospital, Copenhagen NW, Denmark
| | - Henrik Christensen
- Anesthesia & Intensive Care, Herlev & Gentofte Hospital, Hellerup, Denmark
| | - Stine Estrup Damby
- Anesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | | | - Matthew Harmon
- Anesthesia and Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
| | - Uday Kant Soni
- Anesthesia and Intensive Care, Horsens Hospital, Horsens, Denmark
| | | | - Nikolaj Wesche
- Anesthesia and Intensive Care, North Zealand Hospital, Hillerød, Denmark
| | | | - Ulrik Skram
- Anesthesia and Intensive Care, North Zealand Hospital, Hillerød, Denmark
| | - Asger Petersen
- Anesthesia and Intensive Care, Bispebjerg Hospital, Copenhagen NW, Denmark
| | - Thomas Mohr
- Anesthesia and Intensive Care, Gentofte Hospital, Hellerup, Denmark
| | - Tina Waldau
- Anesthesia & Intensive Care, Herlev & Gentofte Hospital, Hellerup, Denmark
| | | | - Ditte Strange
- Anesthesia and Intensive Care, Bispebjerg Hospital, Copenhagen NW, Denmark
| | - Ole Christensen
- Anesthesia and Intensive Care, Roskilde Hospital, Roskilde, Denmark
| | - Nicole P Juffermans
- Anesthesia and Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Else Tønnesen
- Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Dennis Kristensen
- Chip/Department of Infectious Diseases, Rigshospitalet – University of Copenhagen, Copenhagen East, Denmark
| | - Alessandro Cozzi-Lepri
- Chip/Department of Infectious Diseases, Rigshospitalet – University of Copenhagen, Copenhagen East, Denmark
| | - Jens Lundgren
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Ulrik Stæhr Jensen
- Chip/Department of Infectious Diseases, Rigshospitalet – University of Copenhagen , Copehagen East, Denmark
| |
Collapse
|
12
|
Rincon F, Bestle M, Brossner G, Vanderpol J. Unique Uses of Cooling Strategies. Ther Hypothermia Temp Manag 2017; 7:118-121. [PMID: 28813633 DOI: 10.1089/ther.2017.29032.ply] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Fred Rincon
- 1 Department of Neurology, Thomas Jefferson University , Philadelphia, Pennsylvania
| | - Morten Bestle
- 2 Nordsjaellands Hospital, University of Copenhagen , Copenhagen, Denmark
| | - Gregor Brossner
- 3 Neurointensive Care Unit, Department of Neurology, University Hospital , Innsbruck, Austria
| | - Jitka Vanderpol
- 4 Penrith Hospital , Cumbria Partnership NHS Foundation Trust, Cumbria, United Kingdom
| |
Collapse
|
13
|
Berthelsen RE, Itenov T, Perner A, Jensen JU, Ibsen M, Jensen AEK, Bestle M. Forced fluid removal versus usual care in intensive care patients with high-risk acute kidney injury and severe fluid overload (FFAKI): study protocol for a randomised controlled pilot trial. Trials 2017; 18:189. [PMID: 28438182 PMCID: PMC5402636 DOI: 10.1186/s13063-017-1935-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 04/11/2017] [Indexed: 12/16/2022] Open
Abstract
Background Intravenous administration of fluids is an essential part of critical care. While some fluid administration is likely beneficial, there is increasing observational evidence that the development of fluid overload is associated with increased mortality. There are no randomised trials to confirm this association in patients with acute kidney injury. We aim to perform a pilot trial to test the feasibility of forced fluid removal compared to standard care in patients with acute kidney injury and severe fluid overload, the FFAKI trial. Methods Then FFAKI trial is a pilot, multicentre, randomised clinical trial recruiting adult intensive care patients with acute kidney injury and fluid overload, defined as more than 10% of ideal bodyweight. Patients are randomised with concealed allocation to either standard care or forced fluid removal with a therapeutic target of negative net fluid balance ≥1 mL/kg/h. The safety of fluid removal is continually evaluated according to predefined criteria of hypoperfusion: lactate ≥4 mmol/L, mean arterial pressure <50 mmHg or mottling beyond the edge of the kneecaps. If patients fulfil one of these criteria, fluid removal is suspended until hypoperfusion has resolved. The primary outcome measure is fluid balance at 5 days after randomisation and secondary outcomes include mean daily fluid balance, fluid balance at discharge from the intensive care unit, time to neutral fluid balance, number of serious adverse reactions and number of protocol violations. All patients are followed for 90 days. Discussion The FFAKI trial started in October 2015 and, when completed, will provide data to evaluate whether a large trial of forced fluid removal in critically ill patients is feasible. Our primary outcome will show if the experimental intervention leads to a clinically relevant difference in fluid balance, which could prove beneficial in intensive care patients with acute kidney injury. Trial registration EudraCT, identifier: 2015-001701-13. Registered on 19 September 2015; ClinicalTrials.gov, identifier: NCT02458157. Registered on 21 May 2015; Danish Ethics Committee, identifier: H-15009589H. Registered on 22 September 2015; Danish Health and Medicines Authority, identifier: 2015070013. Registered on 11 August 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1935-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Theis Itenov
- Department of Intensive Care, Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, Copenhagen, Denmark
| | - Jens-Ulrik Jensen
- CHIP & PERSIMUNE, Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Michael Ibsen
- Department of Intensive Care, Nordsjællands Hospital, Hillerød, Denmark
| | | | - Morten Bestle
- Department of Intensive Care, Nordsjællands Hospital, Hillerød, Denmark
| |
Collapse
|
14
|
Hjortrup PB, Haase N, Wetterslev J, Lange T, Bundgaard H, Rasmussen BS, Dey N, Wilkman E, Christensen L, Lodahl D, Bestle M, Perner A. Effects of fluid restriction on measures of circulatory efficacy in adults with septic shock. Acta Anaesthesiol Scand 2017; 61:390-398. [PMID: 28150304 DOI: 10.1111/aas.12862] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/14/2016] [Accepted: 12/24/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND The haemodynamic consequences of fluid resuscitation in septic shock have not been fully elucidated. Therefore, we assessed circulatory effects in the first 24 h of restriction of resuscitation fluid as compared to standard care in intensive care unit (ICU) patients with septic shock. METHODS This was a post-hoc analysis of the multicentre CLASSIC randomised trial in which patients with septic shock, who had received the initial fluid resuscitation, were randomised to a protocol restricting resuscitation fluid or a standard care protocol in nine ICUs. The highest plasma lactate, highest dose of noradrenaline, and the urinary output were recorded in five time frames in the first 24 h after randomisation. We used multiple linear mixed effects models to compare the two groups. RESULTS We included all 151 randomised patients; the cumulated fluid resuscitation volume in the first 24 h after randomisation was median 500 ml (Interquartile range (IQR) 0-1500) and 1250 ml (500-2500) in the fluid restriction group and standard care group, respectively. The estimated differences in the fluid restriction group vs. the standard care group were 0.1 mM (95% confidence interval -0.7 to 0.9; P = 0.86) for lactate, 0.01 μg/kg/min (-0.02 to 0.05; P = 0.48) for dose of noradrenaline, and -0.1 ml/kg/h (-0.3 to 0.2; P = 0.70) for urinary output during the first 24 h after randomisation. CONCLUSIONS We observed no indications of worsening of measures of circulatory efficacy in the first 24 h of restriction of resuscitation fluid as compared with standard care in adults with septic shock who had received initial resuscitation.
Collapse
Affiliation(s)
- P. B. Hjortrup
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - N. Haase
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - T. Lange
- Department of Biostatistics; University of Copenhagen; Copenhagen Denmark
- Center for Statistical Science; Peking University; Peking China
| | - H. Bundgaard
- Department of Intensive Care; Randers Hospital; Randers Denmark
| | - B. S. Rasmussen
- Department of Intensive Care; Aalborg University Hospital; Aalborg Denmark
| | - N. Dey
- Department of Intensive Care; Herning Hospital; Herning Denmark
| | - E. Wilkman
- Department of Intensive Care; Helsinki University Hospital; Helsinki Finland
| | - L. Christensen
- Department of Intensive Care; Holbaek Hospital; Holbaek Denmark
| | - D. Lodahl
- Department of Intensive Care; Holstebro Hospital; Holstebro Denmark
| | - M. Bestle
- Department of Intensive Care; Nordsjaellands Hospital; Hillerod Denmark
| | - A. Perner
- Department of Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| |
Collapse
|
15
|
Poulsen CG, Bestle M, Boesby L. [Successful treatment of severe dabigatran intoxication with idarucizumab in a patient with acute kidney injury]. Ugeskr Laeger 2017; 179:V08160562. [PMID: 28397672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In the course of an uncomplicated sigmoidostomy a 63-year-old male who had severe comorbidity developed a critical bleeding due to dabigatran intoxication induced by acute kidney injury. Massive blood transfusions, tranexamic acid, Octaplex and haemodialysis were not effective. Administration of idarucizumab induced immediate clinical and paraclinical improvement. Dabigatran should be carefully administrated in patients who have any degree of renal insufficiency. Idarucizumab may be effective in severe bleeding caused by dabigatran.
Collapse
|
16
|
Jensen JU, Peters L, Johansen ME, Itenov TS, Bestle M, Lauritsen AØ, Mohr T, Thormar K, Løken J, Søe-Jensen P, Christensen PH, Andersen MH, Lundgren B, Grarup J, Lundgren J. Non-recognized Liver Impairment in Infected Critically Ill Patients Is Frequent and Hazardous. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
17
|
Vester-Andersen M, Waldau T, Wetterslev J, Møller MH, Rosenberg J, Jørgensen LN, Jakobsen JC, Møller AM, Gillesberg IE, Jakobsen HL, Hansen EG, Poulsen LM, Skovdal J, Søgaard EK, Bestle M, Vilandt J, Rosenberg I, Itenov TS, Pedersen J, Madsen MR, Maschmann C, Rasmussen M, Jessen C, Bugge L. Randomized multicentre feasibility trial of intermediate care versus standard ward care after emergency abdominal surgery (InCare trial). Br J Surg 2015; 102:619-29. [DOI: 10.1002/bjs.9749] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/06/2014] [Accepted: 11/14/2014] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Emergency abdominal surgery carries a considerable risk of death and postoperative complications. Early detection and timely management of complications may reduce mortality. The aim was to evaluate the effect and feasibility of intermediate care compared with standard ward care in patients who had emergency abdominal surgery.
Methods
This was a randomized clinical trial carried out in seven Danish hospitals. Eligible for inclusion were patients with an Acute Physiology And Chronic Health Evaluation (APACHE) II score of at least 10 who were ready to be transferred to the surgical ward within 24 h of emergency abdominal surgery. Participants were randomized to either intermediate care or standard surgical ward care after surgery. The primary outcome was 30-day mortality.
Results
In total, 286 patients were included in the modified intention-to-treat analysis. The trial was terminated after the interim analysis owing to slow recruitment and a lower than expected mortality rate. Eleven (7·6 per cent) of 144 patients assigned to intermediate care and 12 (8·5 per cent) of 142 patients assigned to ward care died within 30 days of surgery (odds ratio 0·91, 95 per cent c.i. 0·38 to 2·16; P = 0·828). Thirty (20·8 per cent) of 144 patients assigned to intermediate care and 37 (26·1 per cent) of 142 assigned to ward care died within the total observation period (hazard ratio 0·78, 95 per cent c.i. 0·48 to 1·26; P = 0·310).
Conclusion
Postoperative intermediate care had no statistically significant effect on 30-day mortality after emergency abdominal surgery, nor any effect on secondary outcomes. The trial was stopped prematurely owing to slow recruitment and a much lower than expected mortality rate among the enrolled patients. Registration number: NCT01209663 (http://www.clinicaltrials.gov).
Collapse
Affiliation(s)
- M Vester-Andersen
- Department of Anaesthesiology and Intensive Care Medicine, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - T Waldau
- Department of Anaesthesiology and Intensive Care Medicine, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - J Wetterslev
- Department of Copenhagen Trial Unit, Centre for Clinical Intervention Research, Herlev, Denmark
| | - M H Møller
- Department of Intensive Care Medicine – 4131, Rigshospitalet, University of Copenhagen, Herlev, Denmark
| | - J Rosenberg
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - L N Jørgensen
- Digestive Disease Centre, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - J C Jakobsen
- Department of Copenhagen Trial Unit, Centre for Clinical Intervention Research, Herlev, Denmark
| | - A M Møller
- Department of Anaesthesiology and Intensive Care Medicine, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | | | | | | | | | | | | | - M Bestle
- Hospital of North Zealand, Hillerød
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Rosland RG, Hagen MU, Haase N, Holst LB, Plambech M, Madsen KR, Søe-Jensen P, Poulsen LM, Bestle M, Perner A. Red blood cell transfusion in septic shock - clinical characteristics and outcome of unselected patients in a prospective, multicentre cohort. Scand J Trauma Resusc Emerg Med 2014; 22:14. [PMID: 24571858 PMCID: PMC3938972 DOI: 10.1186/1757-7241-22-14] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 02/24/2014] [Indexed: 12/20/2022] Open
Abstract
Background Treating anaemia with red blood cell (RBC) transfusion is frequent, but controversial, in patients with septic shock. Therefore we assessed characteristics and outcome associated with RBC transfusion in this group of high risk patients. Methods We did a prospective cohort study at 7 general intensive care units (ICUs) including all adult patients with septic shock in a 5-month period. Results Ninety-five of the 213 included patients (45%) received median 3 (interquartile range 2–5) RBC units during shock. The median pre-transfusion haemoglobin level was 8.1 (7.4–8.9) g/dl and independent of shock day and bleeding. Patients with cardiovascular disease were transfused at higher haemoglobin levels. Transfused patients had higher Simplified Acute Physiology Score (SAPS) II (56 (45-69) vs. 48 (37-61), p = 0.0005), more bleeding episodes, lower haemoglobin levels days 1 to 5, higher Sepsis-related Organ Failure Assessment (SOFA) scores (days 1 and 5), more days in shock (5 (3-10) vs. 2 (2-4), p = 0.0001), more days in ICU (10 (4-19) vs. 4 (2-8), p = 0.0001) and higher 90-day mortality (66 vs. 43%, p = 0.001). The latter association was lost after adjustment for admission category and SAPS II and SOFA-score on day 1. Conclusions The decision to transfuse patients with septic shock was likely affected by disease severity and bleeding, but haemoglobin level was the only measure that consistently differed between transfused and non-transfused patients.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark.
| |
Collapse
|
19
|
Vester-Andersen M, Waldau T, Wetterslev J, Møller MH, Rosenberg J, Jørgensen LN, Gillesberg I, Jakobsen HL, Hansen EG, Poulsen LM, Skovdal J, Søgaard EK, Bestle M, Vilandt J, Rosenberg I, Berthelsen RE, Pedersen J, Madsen MR, Feurstein T, Busse MJ, Andersen JDH, Maschmann C, Rasmussen M, Jessen C, Bugge L, Ørding H, Møller AM. Effect of intermediate care on mortality following emergency abdominal surgery. The InCare trial: study protocol, rationale and feasibility of a randomised multicentre trial. Trials 2013; 14:37. [PMID: 23374977 PMCID: PMC3575365 DOI: 10.1186/1745-6215-14-37] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 01/25/2013] [Indexed: 01/31/2023] Open
Abstract
Background Emergency abdominal surgery carries a 15% to 20% short-term mortality rate. Postoperative medical complications are strongly associated with increased mortality. Recent research suggests that timely recognition and effective management of complications may reduce mortality. The aim of the present trial is to evaluate the effect of postoperative intermediate care following emergency major abdominal surgery in high-risk patients. Methods and design The InCare trial is a randomised, parallel-group, non-blinded clinical trial with 1:1 allocation. Patients undergoing emergency laparotomy or laparoscopic surgery with a perioperative Acute Physiology and Chronic Health Evaluation II score of 10 or above, who are ready to be transferred to the surgical ward within 24 h of surgery are allocated to either intermediate care for 48 h, or surgical ward care. The primary outcome measure is all-cause 30-day mortality. We aim to enrol 400 patients in seven Danish hospitals. The sample size allows us to detect or refute a 34% relative risk reduction of mortality with 80% power. Discussion This trial evaluates the benefits and possible harm of intermediate care. The results may potentially influence the survival of many high-risk surgical patients. As a pioneer trial in the area, it will provide important data on the feasibility of future large-scale randomised clinical trials evaluating different levels of postoperative care. Trial registration Clinicaltrials.gov identifier: NCT01209663
Collapse
Affiliation(s)
- Morten Vester-Andersen
- Department of Anaesthesiology and Intensive Care Medicine, Herlev Hospital, Copenhagen University, Herlev Ringvej 75, DK-2730 Herlev, Denmark.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, Madsen KR, Møller MH, Elkjær JM, Poulsen LM, Bendtsen A, Winding R, Steensen M, Berezowicz P, Søe-Jensen P, Bestle M, Strand K, Wiis J, White JO, Thornberg KJ, Quist L, Nielsen J, Andersen LH, Holst LB, Thormar K, Kjældgaard AL, Fabritius ML, Mondrup F, Pott FC, Møller TP, Winkel P, Wetterslev J. Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med 2012; 367:124-34. [PMID: 22738085 DOI: 10.1056/nejmoa1204242] [Citation(s) in RCA: 1110] [Impact Index Per Article: 92.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hydroxyethyl starch (HES) [corrected] is widely used for fluid resuscitation in intensive care units (ICUs), but its safety and efficacy have not been established in patients with severe sepsis. METHODS In this multicenter, parallel-group, blinded trial, we randomly assigned patients with severe sepsis to fluid resuscitation in the ICU with either 6% HES 130/0.42 (Tetraspan) or Ringer's acetate at a dose of up to 33 ml per kilogram of ideal body weight per day. The primary outcome measure was either death or end-stage kidney failure (dependence on dialysis) at 90 days after randomization. RESULTS Of the 804 patients who underwent randomization, 798 were included in the modified intention-to-treat population. The two intervention groups had similar baseline characteristics. At 90 days after randomization, 201 of 398 patients (51%) assigned to HES 130/0.42 had died, as compared with 172 of 400 patients (43%) assigned to Ringer's acetate (relative risk, 1.17; 95% confidence interval [CI], 1.01 to 1.36; P=0.03); 1 patient in each group had end-stage kidney failure. In the 90-day period, 87 patients (22%) assigned to HES 130/0.42 were treated with renal-replacement therapy versus 65 patients (16%) assigned to Ringer's acetate (relative risk, 1.35; 95% CI, 1.01 to 1.80; P=0.04), and 38 patients (10%) and 25 patients (6%), respectively, had severe bleeding (relative risk, 1.52; 95% CI, 0.94 to 2.48; P=0.09). The results were supported by multivariate analyses, with adjustment for known risk factors for death or acute kidney injury at baseline. CONCLUSIONS Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.42 had an increased risk of death at day 90 and were more likely to require renal-replacement therapy, as compared with those receiving Ringer's acetate. (Funded by the Danish Research Council and others; 6S ClinicalTrials.gov number, NCT00962156.).
Collapse
Affiliation(s)
- Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Perner A, Haase N, Wetterslev J, Aneman A, Tenhunen J, Guttormsen AB, Klemenzson G, Pott F, Bødker KD, Bådstøløkken PM, Bendtsen A, Søe-Jensen P, Tousi H, Bestle M, Pawlowicz M, Winding R, Bülow HH, Kancir C, Steensen M, Nielsen J, Fogh B, Madsen KR, Larsen NH, Carlsson M, Wiis J, Petersen JA, Iversen S, Schøidt O, Leivdal S, Berezowicz P, Pettilä V, Ruokonen E, Klepstad P, Karlsson S, Kaukonen M, Rutanen J, Karason S, Kjældgaard AL, Holst LB, Wernerman J. Comparing the effect of hydroxyethyl starch 130/0.4 with balanced crystalloid solution on mortality and kidney failure in patients with severe sepsis (6S--Scandinavian Starch for Severe Sepsis/Septic Shock trial): study protocol, design and rationale for a double-blinded, randomised clinical trial. Trials 2011; 12:24. [PMID: 21269526 PMCID: PMC3040153 DOI: 10.1186/1745-6215-12-24] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 01/27/2011] [Indexed: 12/14/2022] Open
Abstract
Background By tradition colloid solutions have been used to obtain fast circulatory stabilisation in shock, but high molecular weight hydroxyethyl starch (HES) may cause acute kidney failure in patients with severe sepsis. Now lower molecular weight HES 130/0.4 is the preferred colloid in Scandinavian intensive care units (ICUs) and 1st choice fluid for patients with severe sepsis. However, HES 130/0.4 is largely unstudied in patients with severe sepsis. Methods/Design The 6S trial will randomise 800 patients with severe sepsis in 30 Scandinavian ICUs to masked fluid resuscitation using either 6% HES 130/0.4 in Ringer's acetate or Ringer's acetate alone. The composite endpoint of 90-day mortality or end-stage kidney failure is the primary outcome measure. The secondary outcome measures are severe bleeding or allergic reactions, organ failure, acute kidney failure, days alive without renal replacement therapy or ventilator support and 28-day and 1/2- and one-year mortality. The sample size will allow the detection of a 10% absolute difference between the two groups in the composite endpoint with a power of 80%. Discussion The 6S trial will provide important safety and efficacy data on the use of HES 130/0.4 in patients with severe sepsis. The effects on mortality, dialysis-dependency, time on ventilator, bleeding and markers of resuscitation, metabolism, kidney failure, and coagulation will be assessed. Trial Registration ClinicalTrials.gov: NCT00962156
Collapse
Affiliation(s)
- Anders Perner
- Department of Intensive Care, Centre of Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Denmark.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Jensen JU, Lundgren B, Hein L, Mohr T, Petersen PL, Andersen LH, Lauritsen AO, Hougaard S, Mantoni T, Bømler B, Thornberg KJ, Thormar K, Løken J, Steensen M, Carl P, Petersen JA, Tousi H, Søe-Jensen P, Bestle M, Hestad S, Andersen MH, Fjeldborg P, Larsen KM, Rossau C, Thomsen CB, Ostergaard C, Kjaer J, Grarup J, Lundgren JD. The Procalcitonin And Survival Study (PASS) - a randomised multi-center investigator-initiated trial to investigate whether daily measurements biomarker Procalcitonin and pro-active diagnostic and therapeutic responses to abnormal Procalcitonin levels, can improve survival in intensive care unit patients. Calculated sample size (target population): 1000 patients. BMC Infect Dis 2008; 8:91. [PMID: 18620598 PMCID: PMC2491622 DOI: 10.1186/1471-2334-8-91] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Accepted: 07/13/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sepsis and complications to sepsis are major causes of mortality in critically ill patients. Rapid treatment of sepsis is of crucial importance for survival of patients. The infectious status of the critically ill patient is often difficult to assess because symptoms cannot be expressed and signs may present atypically. The established biological markers of inflammation (leucocytes, C-reactive protein) may often be influenced by other parameters than infection, and may be unacceptably slowly released after progression of an infection. At the same time, lack of a relevant antimicrobial therapy in an early course of infection may be fatal for the patient. Specific and rapid markers of bacterial infection have been sought for use in these patients. METHODS Multi-centre randomized controlled interventional trial. Powered for superiority and non-inferiority on all measured end points. Complies with, "Good Clinical Practice" (ICH-GCP Guideline (CPMP/ICH/135/95, Directive 2001/20/EC)). Inclusion: 1) Age > or = 18 years of age, 2) Admitted to the participating intensive care units, 3) Signed written informed consent.Exclusion: 1) Known hyper-bilirubinaemia. or hypertriglyceridaemia, 2) Likely that safety is compromised by blood sampling, 3) Pregnant or breast feeding. Computerized Randomisation: Two arms (1:1), n = 500 per arm: Arm 1: standard of care. Arm 2: standard of care and Procalcitonin guided diagnostics and treatment of infection. Primary Trial Objective: To address whether daily Procalcitonin measurements and immediate diagnostic and therapeutic response on day-to-day changes in procalcitonin can reduce the mortality of critically ill patients. DISCUSSION For the first time ever, a mortality-endpoint, large scale randomized controlled trial with a biomarker-guided strategy compared to the best standard of care, is conducted in an Intensive care setting. Results will, with a high statistical power answer the question: Can the survival of critically ill patients be improved by actively using biomarker procalcitonin in the treatment of infections? 700 critically ill patients are currently included of 1000 planned (June 2008). Two interim analyses have been passed without any safety or futility issues, and the third interim analysis is soon to take place. Trial registration number at clinicaltrials.gov: Id. nr.: NCT00271752).
Collapse
Affiliation(s)
- Jens-Ulrik Jensen
- Dept. Of Clinical Microbiology 445, Hvidovre Hospital, Kettegård Allé 30, DK-2650, Hvidovre, Denmark.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Juul AB, Wetterslev J, Gluud C, Kofoed-Enevoldsen A, Jensen G, Callesen T, Nørgaard P, Fruergaard K, Bestle M, Vedelsdal R, Miran A, Jacobsen J, Roed J, Mortensen MB, Jørgensen L, Jørgensen J, Rovsing ML, Petersen PL, Pott F, Haas M, Albret R, Nielsen LL, Johansson G, Stjernholm P, Mølgaard Y, Foss NB, Elkjaer J, Dehlie B, Boysen K, Zaric D, Munksgaard A, Madsen JB, Øberg B, Khanykin B, Blemmer T, Yndgaard S, Perko G, Wang LP, Winkel P, Hilden J, Jensen P, Salas N. Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ 2006; 332:1482. [PMID: 16793810 PMCID: PMC1482337 DOI: 10.1136/bmj.332.7556.1482] [Citation(s) in RCA: 260] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To evaluate the long term effects of perioperative beta blockade on mortality and cardiac morbidity in patients with diabetes undergoing major non-cardiac surgery. DESIGN Randomised placebo controlled and blinded multicentre trial. Analyses were by intention to treat. SETTING University anaesthesia and surgical centres and one coordinating centre. PARTICIPANTS 921 patients aged > 39 scheduled for major non-cardiac surgery. INTERVENTIONS 100 mg metoprolol controlled and extended release or placebo administered from the day before surgery to a maximum of eight perioperative days. MAIN OUTCOME MEASURES The composite primary outcome measure was time to all cause mortality, acute myocardial infarction, unstable angina, or congestive heart failure. Secondary outcome measures were time to all cause mortality, cardiac mortality, and non-fatal cardiac morbidity. RESULTS Mean duration of intervention was 4.6 days in the metoprolol group and 4.9 days in the placebo group. Metoprolol significantly reduced the mean heart rate by 11% (95% confidence interval 9% to 13%) and mean blood pressure by 3% (1% to 5%). The primary outcome occurred in 99 of 462 patients in the metoprolol group (21%) and 93 of 459 patients in the placebo group (20%) (hazard ratio 1.06, 0.80 to 1.41) during a median follow-up of 18 months (range 6-30). All cause mortality was 16% (74/462) in the metoprolol group and 16% (72/459) in the placebo group (1.03, 0.74 to 1.42). The difference in risk for the proportion of patients with serious adverse events was 2.4% (- 0.8% to 5.6%). CONCLUSIONS Perioperative metoprolol did not significantly affect mortality and cardiac morbidity in these patients with diabetes. Confidence intervals, however, were wide, and the issue needs reassessment. TRIAL REGISTRATION Current Controlled Trials ISRCTN58485613.
Collapse
Affiliation(s)
- Anne Benedicte Juul
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, H:S Rigshospitalet, Copenhagen University Hospital, Denmark.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Pump B, Gabrielsen A, Christensen NJ, Bie P, Bestle M, Norsk P. Mechanisms of inhibition of vasopressin release during moderate antiorthostatic posture change in humans. Am J Physiol 1999; 277:R229-35. [PMID: 10409277 DOI: 10.1152/ajpregu.1999.277.1.r229] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The hypothesis was tested that the carotid baroreceptor stimulation caused by a posture change from upright seated with legs horizontal (Seat) to supine (Sup) participates in the suppression of arginine vasopressin (AVP) release. Ten healthy males underwent this posture change for 30 min without or with simultaneous application of lower body negative pressure (LBNP) adjusted to maintain left atrial diameter (LAD) at the Seat level. Throughout Sup, mean arterial pressure and heart rate decreased from 98 +/- 2 to 91 +/- 2 mmHg and from 63 +/- 2 to 55 +/- 2 beats/min (P < 0.05), respectively, whereas the corresponding decreases during Sup + LBNP were attenuated and of shorter duration (98 +/- 2 to 93 +/- 2 mmHg and 62 +/- 2 to 58 +/- 3 beats/min, P < 0.05). During Sup, LAD increased from 30 +/- 1 to 33 +/- 1 mm, and arterial pulse pressure (PP) increased from 40 +/- 2 to 47 +/- 2 mmHg, whereas plasma AVP decreased from 0.9 +/- 0.2 to 0.5 +/- 0.1 pg/ml (P < 0.05), and plasma norepinephrine (NE) decreased from 176 +/- 20 to 125 +/- 16 pg/ml (P < 0.05). During Sup + LBNP, there were no changes in LAD, PP, plasma AVP, or NE. In conclusion, vasopressin secretion is suppressed during an antiorthostatic posture change, which increases carotid sinus pressure, PP, and LAD. The suppression is absent when PP and LAD are prevented from increasing and is thus critically dependent on at least one of these stimuli.
Collapse
Affiliation(s)
- B Pump
- Danish Aerospace Medical Centre of Research, Rigshospitalet 7805, Denmark
| | | | | | | | | | | |
Collapse
|