Shock
Conditions
Keywords
Shock, Preterm infant, Dobutamine
Brief summary
Haemodynamic insufficiency after birth is seen commonly in babies born prematurely and is associated with adverse outcomes. In current clinical practice, a combination of blood pressure and clinical signs is used to guide therapy. However, blood pressure is a poor surrogate of systemic and organ (brain) blood flow distribution during transitional circulation. This state is characterised by increased peripheral vascular resistance and increased afterload causing myocardial depression and impaired blood flow distribution in spite of 'normal' blood pressure. Echocardiography-Doppler (Echo-D) measurement of superior vena cava (SVC) flow has been proposed as a more clinically relevant marker of circulatory impairment shortly after birth than systemic hypotension. When there is low SVC flow, several small-scale clinical trials have suggested dobutamine as the optimal therapeutic option. However the associations between SVC flow and short- and long- term outcomes are not strong enough to allow SVC flow alone to be the basis for the inclusion of patients into a confirmatory trial to demonstrate the efficacy and safety of dobutamine. NeoCirc-001 - The primary objective is to answer some important questions required for the design of a subsequent placebo-controlled trial (NeoCirc-003), which will evaluate the effectiveness of a new neonatal formulation of dobutamine to treat haemodynamic insufficiency in the first 72 hours after birth in babies born at less than 33 weeks' gestation. Observational data will be collected from this population with a view to determining the degree to which diagnostic measures influence treatment decisions. The primary outcome is death or worst cranial ultrasound (CUS) appearance at or before 36 weeks' gestation. NeoCirc-001A - The primary objective is to estimate the elimination half-life, and consequently the time to steady-state of dobutamine in extremely premature neonates. NeoCirc-001B - The primary objective is to construct a population pharmacokinetic pharmacodynamic model that will be validated using samples collected during the confirmatory trial (NeoCirc-003).
Interventions
DRUGDobutamine
Infants who meet the definition of poor perfusion state will be treated at the discretion of the responsible physician following the standard local policies. The interventions will be dobutamine from a new neonatal formulation developed for NeoCirc and/or other treatments (including any other cardiovascular drug or volume replacement with normal saline).
Sponsors
Hospital Universitario La Paz
Brighton and Sussex University Hospitals NHS Trust
University of Luebeck
Servicio Vasco de Salud Osakidetza, Spain
University of Liverpool
Vest Children´s Hospital, Germany
Datteln University Witten-Herdecke
Iuliu Hatieganu University of Medicine and Pharmacy
Semmelweis University
University of Pecs
Gazi University
Tufts Medical Center
Hannover Medical School
Onorach Clinical Dundee, Scotland
Proveca Limited Daresbury, England
Institut National de la Santé Et de la Recherche Médicale, France
Fundacion para la Investigacion Biomedica del Hospital Universitario la Paz
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
No minimum to 72 Hours
Healthy volunteers
No
Inclusion criteria
for NeoCirc-001, 001A and 001B - Target population for informed consent: * neonates 24 to 32+6 weeks´ gestation, * postnatal age \<72 hours; Infants eligible for circulatory failure pathway: * parental informed consent obtained; * The infants will be assessed, as per routine clinical practice, for clinical signs indicating infants at risk of poor perfusion, and will be recruited if they develop haemodynamic insufficiency defined as: either two or more of: (i) Mean blood pressure (MBP) \< gestational age (GA)-1 mmHg (invasive/non-invasive, two readings 15 min apart); (ii) SVC flow \< 51 ml/kg/min; (iii) capillary refill time (CRT) \> 4 sec; (iv) Lactate \> 4 mmol/l (v) Base excess \<-9 mmol/l or: MBP \< GA -5 mmHg (invasive/non-invasive, two readings 15 min apart)
Exclusion criteria
NeoCirc-001, 001A and 001B - * non-viability; * congenital hydrops or malformations likely to affect cardiovascular adaptation; * surgery planned within 72 hours of birth; * chromosomal anomalies; * informed consent form (ICF) not signed.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Half-life of the neonatal formulation of dobutamine. | The first sample will be drawn after the end of the infusion, at the time when dobutamine ceases. The second sample will be taken at different study time points after the end of infusion (from 5 min to 6 hours). | NeoCirc-001A: Half-life of the neonatal formulation of dobutamine. The first sample will be drawn after the end of the infusion, at the time when dobutamine ceases reaching the systemic circulation of the neonate, defined as time end (te). To calculate the end of infusion (te) the dead space used in each unit will be taken into account (see below). The second sample will be taken at different study time points after the end of infusion: * 5 min after te * 15 min after te * 45 min after te * 2 hours after te * 6 hours after te Two infants will be allocated to each time point. Sampling times will be assigned randomly to the patients. |
| Mortality, or intraventricular haemorrhage (IVH) grades 3 or 4, or cystic and non-cystic periventricular leukomalacia (PVL), or porencephalic cysts, ventriculomegaly, or cerebellar haemorrhage. | at 36 (+/-2 weeks) postmenstrual age | A composite endpoint is defined as follows: treatment failure is when one of the following is true at or before gestational age 36 (+/-2 weeks), when all surviving patients will have a cranial ultrasound (CUS)- 1. Neonate dies, or 2. Intraventricular haemorrhage (IVH) grades 3 or 4, or 3. cystic and non-cystic periventricular leukomalacia (PVL), or 4. porencephalic cysts, ventriculomegaly, or cerebellar haemorrhage. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Arterial blood pressure | First 72 hours of life (data collection every 9 ±3 hrs) | Short-term outcomes of biomarkers for circulatory assessment while a patient is receiving cardiovascular support |
| Capillary refill time | First 72 hours of life (data collection every 9 ±3 hrs) | Short-term outcomes of biomarkers for circulatory assessment while a patient is receiving cardiovascular support |
| Urine output | First 72 hours of life (data collection every 9 ±3 hrs) | Short-term outcomes of biomarkers for circulatory assessment while a patient is receiving cardiovascular support |
| Blood lactate concentration | First 72 hours of life (data collection every 9 ±3 hrs) | Short-term outcomes of biomarkers for circulatory assessment while a patient is receiving cardiovascular support |
| Base excess | First 72 hours of life (data collection every 9 ±3 hrs) | Short-term outcomes of biomarkers for circulatory assessment while a patient is receiving cardiovascular support |
| cerebral regional tissue oxygen saturation (rStO2) | First 72 hours of life (data collection every 6 ±1 hrs) | Cerebral regional tissue oxygen saturation (rStO2) measured by means of near-infrared spectroscopy |
| Background pattern | First 72 hours of life (data collection every 6 ±1 hrs) | Background pattern measured by means of Amplitude-integrated electroencephalography (aEEG/EEG) |
| Right cardiac output | First 72 hours of life (data collection every 9 ±3 hrs) | Short-term outcomes of biomarkers for circulatory assessment while a patient is receiving cardiovascular support |
| Cerebral fractional oxygen extraction (FOE) | First 72 hours of life (data collection every 6 ±1 hrs) | FOE= \[peripheral oxygen saturation (SaO2)-rStO2\] /SaO2 |
| Interburst interval (IBI) | First 72 hours of life (data collection every 6 ±1 hrs) | Interburst interval (IBI) measured by means of Amplitude-integrated electroencephalography (aEEG/EEG) |
| Discontinuity | First 72 hours of life (data collection every 6 ±1 hrs) | Discontinuity measured by means of Amplitude-integrated electroencephalography (aEEG/EEG) |
| Amplitude | Fist 72 hours of life (data collection every 6 ±1 hrs) | The amplitude measured by means of aEEG/EEG |
| Presence of abnormal transients | First 72 hours of life (data collection every 6 ±1 hrs) | The presence of abnormal transients measured by means of aEEG/EEG |
| Mortality | From birth to 36 (+/-2 weeks) postmenstrual age | — |
| Intraventricular haemorrhage 2-4 | From birth to 36 (+/-2 weeks) postmenstrual age | — |
| Survival free of severe brain injury | From birth to 36 (+/-2 weeks) postmenstrual age | Survival free of severe brain injury measured by means of cranial ultrasound studies |
| Hypotension | From birth to 36 (+/-2 weeks) postmenstrual age | — |
| Hypertension | From birth to 36 (+/-2 weeks) postmenstrual age | — |
| Necrotizing enterocolitis | From birth to 36 (+/-2 weeks) postmenstrual age | — |
| Patent ductus (PDA) | From birth to 36 (+/-2 weeks) postmenstrual age | — |
| Retinopathy of prematurity | at 36 (+/-2 weeks) postmenstrual age | — |
| Chronic lung disease | at 36 (+/-2 weeks) postmenstrual age | — |
| Oxygen-dependency at discharge | At discharge | — |
| early infection | From birth to 72 hours after birth | — |
| Nosocomial infection | From birth to 36 (+/-2 weeks) postmenstrual age | — |
| Synchrony | First 72 hours of life (data collection every 6 ±1 hrs) | The synchrony measured by means of aEEG/EEG |
| Superior vena cava flow | First 72 hours of life (data collection every 9 ±3 hrs) | Short-term outcomes of biomarkers for circulatory assessment while a patient is receiving cardiovascular support |
Other
| Measure | Time frame | Description |
|---|---|---|
| Number of participants with adverse events | Daily during the first four days of life, at 36±2 weeks' gestation or discharge and at 38±2 weeks' gestation or discharge | Number of Participants with Adverse Events as a Measure of Safety and Tolerability |
Countries
Spain
Outcome results
None listed