Acute Respiratory Distress Syndrome, Sepsis, Septic Shock
Conditions
Keywords
Organ-substituting technologies, Heart failure, Pulmonary failure, Sepsis, Extracorporeal membrane oxygenation, Adsorber
Brief summary
The implementation of this project will improve the effectiveness of surgical treatment and reduce the level of complications and mortality among patients with heart failure and heart failure in the terminal stage. The goal of the study. Improvement of organ-substituting technologies in the treatment of heart and respiratory failure. Objectives of the study. Objective 1. To study the restoration of organ function during implantation of extracorporeal membrane oxygenation (ECMO), as an organ replacement, in cardiac and / or respiratory failure. Objective 2. To study the results of applying organ-substituting technologies in the treatment of sepsis.
Detailed description
The implementation of this project will improve the effectiveness of surgical treatment and reduce the level of complications and mortality among patients with heart failure and heart failure in the terminal stage. 2.2. The goal of the program. Improvement of organ-substituting technologies in the treatment of heart and respiratory failure. 2.3. Objectives of the program. Objective 1. To study the restoration of organ function during implantation of extracorporeal membrane oxygenation (ECMO), as an organ replacement, in cardiac and/or respiratory failure. Subtask 1.1. Evaluation of the recovery of organ function during ECMO using extracorporal hemo correction procedure. Subtask 1.2. Evaluation of the normalization of the organism's immune response and restoration of organ function when conducting ECMO using the extracorporeal cytokine adsorber. Subtask 1.3. Evaluation of the normalization of the organism's immune response and restoration of organ function when conducting ECMO using the extracorporeal hemoperfusion cartridge. Objective 2. To study the results of applying organ-substituting technologies in the treatment of sepsis. Subtask 2.1. Assessment of the recovery of organ function in the application of extracorporal hemo correction in septic patients. Subtask 2.2. Evaluation of the normalization of the organism immune response and restoration of organ function when using the extracorporeal cytokine adsorber in septic patients. Subtask 2.3. Evaluation of the normalization of the organism's immune response and restoration of organ function when using the extracorporeal hemoperfusion cartridge. In this study, will be developed methods to restore the function of affected organs after implantation of ECMO and patients with sepsis in combination with extracorporeal hem correction, which will improve the results of surgical treatment of patients with end-cardiac and respiratory failure. New methods developed to restore the function of affected organs after implantation of mechanical support devices and patients with sepsis will be of great importance both for Kazakhstan and for countries with similar categories of patients, which will improve the efficiency of surgical treatment and reduce the level of complications and mortality. Clinical research data will form the basis of practical protocols for extracorporeal membrane oxygenation (ECMO) and patients with sepsis, which will improve organ repair, reduce postoperative complications, improve quality of life and reduce mortality after surgery. Research methods and ethical issues Patients before implantation of ECMO and/or patients with sepsis will be enrolled in the study after giving a written, signed informed consent. The participants will be randomized into 3 groups: * Intervention group #1 a cytokine adsorber will be used (30 patients): patients on ECMO - subgroup A; septic patients - subgroup B. * Intervention group #2 an extracorporeal hemoperfusion cartridge will be used (30 patients): patients on ECMO - subgroup C, septic patients - subgroup D. * Control group #3 without using extracorporeal adsorber (30 patients): patients on ECMO subgroup - E, septic patients - subgroup F. The investigators will collect demographic, clinical, and laboratory data about patients before, during, and after the operation The incidence of early cellular or humoral rejection, length of ventilation, ICU and hospital stay, the use of vasopressors and inotropes in the perioperative period, and incidence of perioperative complications and survival will be documented. The level of cytokines (IL-1, IL-6, IL-8, IL-10, tumor necrosis factor-alfa) and complements before, during, and after the use of ECMO, patients with sepsis will be determined if the investigators find the relevant differences between the two groups in clinical variables. Study Design Study Type: Interventional (Clinical Trial) Estimated Enrollment: 90 Participants Allocation: randomized Interventional Model: Parallel assignment Masking: None (Open Label)
Interventions
DEVICECytokine adsorber filter
• Intervention group #1 a cytokine adsorber will be used (30 patients): patients on ECMO - subgroup A; septic patients - subgroup B.
DEVICEExtracorporeal hemoperfusion cartridge
• Intervention group #2 an extracorporeal hemoperfusion cartridge will be used (30 patients): patients on ECMO - subgroup C, septic patients - subgroup D.
Sponsors
Ministry of Education and Science, Republic of Kazakhstan
National Research Center for Cardiac Surgery, Kazakhstan
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
Study Design Study Type: Interventional (Clinical Trial) Estimated Enrollment: 90 Participants Allocation: randomized Interventional Model: Parallel assignment Masking: None (Open Label)
Eligibility
Sex/Gender
ALL
Age
18 Years to 65 Years
Healthy volunteers
No
Inclusion criteria
\- ICU patients with ECMO: * Hemodynamic support with vasopressors * Procalcitonin level ≥ 1 ng/ml * Invasive hemodynamic monitoring * Written informed content ICU patients with the septic shock of medical origin: * Signs of hypoperfusion: serum lactate \>2 mmol/L, low central venous oxygen saturation (ScvO2) (\<70%) or high ScvO2 (\>85%), metabolic acidosis, oligo-anuria, high venous-to-arterial CO2-gap (dCO2 \>6 mm Hg) * Hemodynamic support with vasopressors * Procalcitonin level ≥ 1 ng/ml * Invasive hemodynamic monitoring * Written informed content
Exclusion criteria
* ICU patients with ECMO: * age \< 18 years * acute liver or kidney failure straight before transplantation * the patient declines to participate in the study ICU patients with the septic shock of medical origin: * Patients under 18 years * Pregnancy (bHCG test positivity) * Surgical intervention in context with the septic insult New York Heart Association IV heart failure * Acute coronary syndrome * Acute hematological malignancies * Immunosuppression, systemic steroid therapy (\>10mg prednisolone/day) * Human immunodeficiency virus infection (HIV) and active AIDS * Patients with donated organs * Thrombocytopenia (\<20.000/ml) * More than 10%-of body surface area with third-degree burn
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Difference of Cytokine response - ECMO patients | 6-24 hours | Level of pro- and anti-inflammatory cytokines (IL-1, IL-6, IL-8, IL-10, tumor necrosis factor-alfa) before initiation of ECMO, 2 hours after initiation ECMO support, at explantation of ECMO support, 6-12-24 hours after explantation of ECMO support. |
| Difference of Cytokine response - Patients with septic shock | 24-48 hours of septic shock | Level of procalcitonin, Level of C-reactive protein, Level of interleukin-1, Level of interleukin-6, Level of interleukin-8, Level of interleukin-10, Level of Tumor Necrosis Factor- αinterleukin-8, interleukin-10, Tumor Necrosis Factor- α at 24, 48 hours. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| SOFA-Score - ECMO patients | 24, 48, 72 hours | Sequential Organ Failure Assessment Score at 24, 48, 72 h (values from 6 to 24, where the higher values explain higher disease severity) |
| adverse event of special interest: blood-clotting in the ECMO system | 30 days | unintended blood-clotting in the ECMO system during operation of the device |
| adverse event of special interest: bleeding complications - ECMO patients | 30 days | major bleeding events |
| Difference of serum interleukin-6 level - Patients with septic shock | 48, 72 hours | Comparison to enrollment or between 3 groups at 48, 72 h |
| Difference of serum interleukin-1β level - Patients with septic shock | 24, 48, 72 hours | Comparison to enrollment or between 3 groups at 24, 48, 72 h |
| Difference of serum interleukin-10 level - Patients with septic shock | 24, 48, 72 hours | Comparison to enrollment or between 3 groups at 24, 48, 72 h |
| Difference of serum procalcitonin level - Patients with septic shock | 24, 48, 72 hours | Comparison to enrollment or between 3 groups at 24, 48, 72 h |
| Inflammatory reaction - Patients with septic shock | 6-24 hours | Level of C reactive protein (CRP), white blood cells and procalcitonin immediately after induction of anesthesia, before initiation of adsorber, 2 hours after initiation of adsorber, at termination of adsorber, 6-12-24 hours after wean of adsorber. |
| Ventilator free days (VFD) - ECMO patients | 30 days | ventilator days. VFD=0, if the patient dies in the first 30 days after randomization |
| Time to extubation from ventilation and explantation from ECMO - ECMO patients | 30 days | Time to extubation from ventilation and explantation from ECMO. Death under ventilation and/or ECMO will be analyzed as a competing event. The time will be censored at the time of last visit for surviving patients under ventilation and/or ECMO. |
| Difference of d-dimers - ECMO patients | 24, 48, 72 hours | Comparison to enrollment or between 3 groups at 24, 48, 72 h |
| Difference of Serum lactate - ECMO patients | 24, 48, 72 hours | Comparison to enrollment or between 3 groups at 24, 48, 72 h |
| serious adverse device effects - ECMO patients | 30 days | serious complications or malfunctions related to the CytoSorb device |
| adverse event of special interest: air in the ECMO system - ECMO patients | 30 days | unintended air in the ECMO system during operation of the device |
Other
| Measure | Time frame | Description |
|---|---|---|
| Fluid substitution and fluid balance | 24, 48, 72 hours | Total fluid\[ml\] substitution and fluid balance \[ml\] at 24, 48, 72 h |
| Length of hospital stay | up to 1 months | Days at hospital |
| Mortality | First 72 hours | The period of occurrence of mortality |
| Vasopressor dosage | 24, 48, 72 hours | Vasopressor dosage of adrenaline, noradrenaline, vasopressin, and dobutamine at 24, 48,72 h |
| Days on intensive care unit (ICU) | 30 days | Days on intensive care unit (ICU) |
| Overall survival time | 30 days | Overall survival time, defined as time from randomization to death. The time will be censored at the time of last visit for surviving patients. |
Countries
Kazakhstan
Contacts
Primary ContactRymbay Kaliyev, MD
Backup ContactZhuldyz Nurmykhametova, MD
Outcome results
None listed