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出境医 / 临床实验 / Early Transcranial Doppler Goal Directed Therapy After Cardiac Arrest: a Pilot Study (GOODYEAR)

Early Transcranial Doppler Goal Directed Therapy After Cardiac Arrest: a Pilot Study (GOODYEAR)

Study Description
Brief Summary:

Hypoxic-ischaemic brain injury (HIBI) is the main cause of death in patients who are comatose after resuscitation from cardiac arrest. Current guidelines recommend to target a mean arterial pressure (MAP) above 65 mmHg to achieve an adequate organ perfusion. Moreover, after cardiac arrest, cerebral autoregulation is dysregulated and cerebral blood flow (CBF) depends on the MAP. A higher blood pressure target could improve cerebral perfusion and HIBI. Transcranial Doppler (TCD) is a non-invasive method to study CBF and its variations induced by MAP.

The aim of this study is to test the feasibility of an early-goal directed hemodynamic management with TCD during the first 12 hours after return of spontaneous circulation (ROSC).


Condition or disease Intervention/treatment Phase
Cardiac Arrest Cerebral Lesion Ischemic Encephalopathy Ischemic Reperfusion Injury Other: MAP increased to optimize cerebral blood flow Other: MAP between 65 and 85 mmHg Not Applicable

Study Design
Layout table for study information
Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 40 participants
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Early Transcranial Doppler Goal Directed Therapy After Cardiac Arrest: a Pilot Study
Estimated Study Start Date : September 2019
Estimated Primary Completion Date : September 2021
Estimated Study Completion Date : December 2021
Arms and Interventions
Arm Intervention/treatment
Experimental: Cerebral hypoperfusion (group A)
Cerebral hypoperfusion will be defined by an abnormal TCD at inclusion (t0) when two of the three measured values are abnormal using the following thresholds: Vm < 30 cm/s, Vd < 20 cm/s, PI > 1.4.
Other: MAP increased to optimize cerebral blood flow
MAP will be increased to 90-100 mmHg with norepinephrine. If TCD is still abnormal with a MAP of 90-100 mmHg, MAP will be increased to 100-110 mmHg. At each step, all CBF determinants will be recorded as well as cardiac output and Veinous jugular oxygen saturation (SvjO2). When TCD is normalized with no complications, MAP will be maintained at 90-100 or 100-110 mmHg during 24 hours.

Active Comparator: Normal cerebral perfusion (group B)
Normal cerebral perfusion will be defined by a normal TCD at inclusion (t0) when two of the three measured values are normal using the following thresholds: Vm > 30 cm/s, Vd > 20 cm/s, PI < 1.4.
Other: MAP between 65 and 85 mmHg
MAP will be maintained between 65-85 mmHg, using a norepinephrine infusion as needed.

Outcome Measures
Primary Outcome Measures :
  1. Proportion of patients in whom the transcranial doppler goal directed therapy will result in a modification of MAP targets [ Time Frame: In the first hour after inclusion ]
    Proportion of patients in whom transcranial doppler goal directed therapy will result in a modification of MAP targets.


Secondary Outcome Measures :
  1. Cerebral blood flow modifications induced by increasing MAP [ Time Frame: At the 6th, 12th, 24th, 48th and 72nd hour after inclusion ]
    Transcranial doppler data modifications induced by increasing MAP to 90-100 mmHg and 100-110 mmHg.

  2. Cerebral oxygenation modifications induced by increasing MAP [ Time Frame: At the 6th, 12th, 24th, 48th and 72nd hour after inclusion ]
    Bulb jugular venous oxygen saturation modifications induced by increasing MAP at 90-100 mmHg and 100-110 mmHg.

  3. Undesirable events induced by increasing MAP [ Time Frame: At te 24th hour after inclusion ]
    Number of cardiovascular events defined by new onset of severe cardiac arrythmias, acute coronary syndromes, cardiogenic pulmonary edema, cardiogenic shock or cardiac arrest

  4. Undesirable events induced by increasing MAP [ Time Frame: At the 72nd hour after inclusion ]
    Number of neurologic events defined by intracranial hematoma or brain death

  5. Plasmatic concentrations of Neuron Specific Enolase [ Time Frame: At the 72nd hour after inclusion ]
    Neuron Specific Enolase (NSE) plasmatic concentrations at H+72h after cardiac arrest

  6. 28 day survival [ Time Frame: 28 days after inclusion ]
    Proportion of patients alive 28 days after inclusion

  7. 90 days survival [ Time Frame: 90 days after inclusion ]
    Proportion of patients alive 90 days after inclusion

  8. Measure of the degree of disability in the activities of daily living of the included patients [ Time Frame: 90 days after inclusion ]

    Modified Rankin scale (MRS) 90 days after inclusion. The scale runs from 0-6, running from perfect health without symptoms to death.

    0 - No symptoms.

    1. - No significant disability. Able to carry out all usual activities, despite some symptoms.
    2. - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.
    3. - Moderate disability. Requires some help, but able to walk unassisted.
    4. - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.
    5. - Severe disability. Requires constant nursing care and attention, bedridden, incontinent.
    6. - Dead.


Eligibility Criteria
Layout table for eligibility information
Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Patients admitted in the Intensive Care Unit (ICU) under mechanical ventilation with a Glasgow Coma Scale ≤ 8/15 after in- or out-of-hospital cardiac arrest
  • Mean arterial pressure between 65 and 85 mmHg with or without vasopressor support

Exclusion Criteria:

  • Age < 18 years old
  • No flow (time between cardiac arrest and the beginning of cardiac massage) > 15 minutes or unknown
  • Low flow ((time between cardiac arrest and ROSC: return of spontaneous circulation)> 60 minutes
  • Time between ROSC and inclusion > 12 hours
  • Transcranial doppler unavailable
  • Cardiac arrythmia
  • Patient under extracorporeal life support before inclusion or at risk of being referred for assistance due to cardiogenic shock with high dose of vasopressors before inclusion (MAP < 65 mmHg with norepinephrine or epinephrine > 1 µg/kg/min or dobutamine > 10 µg/kg/min)
  • Severe cardiac dysfunction defined by left ventricular ejection fraction < 20% or aortic Velocity Time Integral (VTI: measured with trans-thoracic echocardiography) < 14 cm with dobutamine > 10µg/kg/min
  • Patient under Extracorporeal Membrane Oxygenation (ECMO) for Acute Respiratory Distress Syndrome (ARDS) before inclusion
  • Cardiac arrest secondary to brain injury such as stroke, subarachnoid hemorrhage or traumatic brain injury
  • Hemorrhagic shock
  • Any acute pathology that requires strict blood pressure control (aortic dissection, stroke, cardiogenic pulmonary edema with high blood pressure)
  • Decision of withdrawing or withholding life sustaining treatment before inclusion or considered during the first 12 hours of ICU management
  • Patient with a modified Rankin scale (MRS) 4 or 5 prior to resuscitation
  • Pregnancy or lactation
  • Patients already enrolled in another clinical study on cardiac arrest
  • Patients with judicial protection
  • No social security coverage
Contacts and Locations

Contacts
Layout table for location contacts
Contact: Christelle Jadeau, PD 0 (33) 2 43 43 43 43 ext 37 482 cjadeau@ch-lemans.fr

Locations
Layout table for location information
France
Centre Hospitalier Le Mans
Le Mans, France
Contact: Christelle Jadeau, PD    0 (33) 2 43 43 43 43 ext 37 482    cjadeau@ch-lemans.fr   
Principal Investigator: Nicolas Chudeau, MD         
Sponsors and Collaborators
Centre Hospitalier le Mans
Investigators
Layout table for investigator information
Principal Investigator: Nicolas Chudeau, MD Centre Hospitalier Le Mans, Intensive Care Unit
Tracking Information
First Submitted Date  ICMJE June 22, 2019
First Posted Date  ICMJE June 27, 2019
Last Update Posted Date June 27, 2019
Estimated Study Start Date  ICMJE September 2019
Estimated Primary Completion Date September 2021   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: June 26, 2019)
Proportion of patients in whom the transcranial doppler goal directed therapy will result in a modification of MAP targets [ Time Frame: In the first hour after inclusion ]
Proportion of patients in whom transcranial doppler goal directed therapy will result in a modification of MAP targets.
Original Primary Outcome Measures  ICMJE Same as current
Change History No Changes Posted
Current Secondary Outcome Measures  ICMJE
 (submitted: June 26, 2019)
  • Cerebral blood flow modifications induced by increasing MAP [ Time Frame: At the 6th, 12th, 24th, 48th and 72nd hour after inclusion ]
    Transcranial doppler data modifications induced by increasing MAP to 90-100 mmHg and 100-110 mmHg.
  • Cerebral oxygenation modifications induced by increasing MAP [ Time Frame: At the 6th, 12th, 24th, 48th and 72nd hour after inclusion ]
    Bulb jugular venous oxygen saturation modifications induced by increasing MAP at 90-100 mmHg and 100-110 mmHg.
  • Undesirable events induced by increasing MAP [ Time Frame: At te 24th hour after inclusion ]
    Number of cardiovascular events defined by new onset of severe cardiac arrythmias, acute coronary syndromes, cardiogenic pulmonary edema, cardiogenic shock or cardiac arrest
  • Undesirable events induced by increasing MAP [ Time Frame: At the 72nd hour after inclusion ]
    Number of neurologic events defined by intracranial hematoma or brain death
  • Plasmatic concentrations of Neuron Specific Enolase [ Time Frame: At the 72nd hour after inclusion ]
    Neuron Specific Enolase (NSE) plasmatic concentrations at H+72h after cardiac arrest
  • 28 day survival [ Time Frame: 28 days after inclusion ]
    Proportion of patients alive 28 days after inclusion
  • 90 days survival [ Time Frame: 90 days after inclusion ]
    Proportion of patients alive 90 days after inclusion
  • Measure of the degree of disability in the activities of daily living of the included patients [ Time Frame: 90 days after inclusion ]
    Modified Rankin scale (MRS) 90 days after inclusion. The scale runs from 0-6, running from perfect health without symptoms to death. 0 - No symptoms.
    1. - No significant disability. Able to carry out all usual activities, despite some symptoms.
    2. - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.
    3. - Moderate disability. Requires some help, but able to walk unassisted.
    4. - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.
    5. - Severe disability. Requires constant nursing care and attention, bedridden, incontinent.
    6. - Dead.
Original Secondary Outcome Measures  ICMJE Same as current
Current Other Pre-specified Outcome Measures Not Provided
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title  ICMJE Early Transcranial Doppler Goal Directed Therapy After Cardiac Arrest: a Pilot Study
Official Title  ICMJE Early Transcranial Doppler Goal Directed Therapy After Cardiac Arrest: a Pilot Study
Brief Summary

Hypoxic-ischaemic brain injury (HIBI) is the main cause of death in patients who are comatose after resuscitation from cardiac arrest. Current guidelines recommend to target a mean arterial pressure (MAP) above 65 mmHg to achieve an adequate organ perfusion. Moreover, after cardiac arrest, cerebral autoregulation is dysregulated and cerebral blood flow (CBF) depends on the MAP. A higher blood pressure target could improve cerebral perfusion and HIBI. Transcranial Doppler (TCD) is a non-invasive method to study CBF and its variations induced by MAP.

The aim of this study is to test the feasibility of an early-goal directed hemodynamic management with TCD during the first 12 hours after return of spontaneous circulation (ROSC).

Detailed Description Not Provided
Study Type  ICMJE Interventional
Study Phase  ICMJE Not Applicable
Study Design  ICMJE Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Condition  ICMJE
  • Cardiac Arrest
  • Cerebral Lesion
  • Ischemic Encephalopathy
  • Ischemic Reperfusion Injury
Intervention  ICMJE
  • Other: MAP increased to optimize cerebral blood flow
    MAP will be increased to 90-100 mmHg with norepinephrine. If TCD is still abnormal with a MAP of 90-100 mmHg, MAP will be increased to 100-110 mmHg. At each step, all CBF determinants will be recorded as well as cardiac output and Veinous jugular oxygen saturation (SvjO2). When TCD is normalized with no complications, MAP will be maintained at 90-100 or 100-110 mmHg during 24 hours.
  • Other: MAP between 65 and 85 mmHg
    MAP will be maintained between 65-85 mmHg, using a norepinephrine infusion as needed.
Study Arms  ICMJE
  • Experimental: Cerebral hypoperfusion (group A)
    Cerebral hypoperfusion will be defined by an abnormal TCD at inclusion (t0) when two of the three measured values are abnormal using the following thresholds: Vm < 30 cm/s, Vd < 20 cm/s, PI > 1.4.
    Intervention: Other: MAP increased to optimize cerebral blood flow
  • Active Comparator: Normal cerebral perfusion (group B)
    Normal cerebral perfusion will be defined by a normal TCD at inclusion (t0) when two of the three measured values are normal using the following thresholds: Vm > 30 cm/s, Vd > 20 cm/s, PI < 1.4.
    Intervention: Other: MAP between 65 and 85 mmHg
Publications * Not Provided

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Not yet recruiting
Estimated Enrollment  ICMJE
 (submitted: June 26, 2019)
40
Original Estimated Enrollment  ICMJE Same as current
Estimated Study Completion Date  ICMJE December 2021
Estimated Primary Completion Date September 2021   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE

Inclusion Criteria:

  • Patients admitted in the Intensive Care Unit (ICU) under mechanical ventilation with a Glasgow Coma Scale ≤ 8/15 after in- or out-of-hospital cardiac arrest
  • Mean arterial pressure between 65 and 85 mmHg with or without vasopressor support

Exclusion Criteria:

  • Age < 18 years old
  • No flow (time between cardiac arrest and the beginning of cardiac massage) > 15 minutes or unknown
  • Low flow ((time between cardiac arrest and ROSC: return of spontaneous circulation)> 60 minutes
  • Time between ROSC and inclusion > 12 hours
  • Transcranial doppler unavailable
  • Cardiac arrythmia
  • Patient under extracorporeal life support before inclusion or at risk of being referred for assistance due to cardiogenic shock with high dose of vasopressors before inclusion (MAP < 65 mmHg with norepinephrine or epinephrine > 1 µg/kg/min or dobutamine > 10 µg/kg/min)
  • Severe cardiac dysfunction defined by left ventricular ejection fraction < 20% or aortic Velocity Time Integral (VTI: measured with trans-thoracic echocardiography) < 14 cm with dobutamine > 10µg/kg/min
  • Patient under Extracorporeal Membrane Oxygenation (ECMO) for Acute Respiratory Distress Syndrome (ARDS) before inclusion
  • Cardiac arrest secondary to brain injury such as stroke, subarachnoid hemorrhage or traumatic brain injury
  • Hemorrhagic shock
  • Any acute pathology that requires strict blood pressure control (aortic dissection, stroke, cardiogenic pulmonary edema with high blood pressure)
  • Decision of withdrawing or withholding life sustaining treatment before inclusion or considered during the first 12 hours of ICU management
  • Patient with a modified Rankin scale (MRS) 4 or 5 prior to resuscitation
  • Pregnancy or lactation
  • Patients already enrolled in another clinical study on cardiac arrest
  • Patients with judicial protection
  • No social security coverage
Sex/Gender  ICMJE
Sexes Eligible for Study: All
Ages  ICMJE 18 Years and older   (Adult, Older Adult)
Accepts Healthy Volunteers  ICMJE No
Contacts  ICMJE
Contact: Christelle Jadeau, PD 0 (33) 2 43 43 43 43 ext 37 482 cjadeau@ch-lemans.fr
Listed Location Countries  ICMJE France
Removed Location Countries  
 
Administrative Information
NCT Number  ICMJE NCT04000334
Other Study ID Numbers  ICMJE CHM-2019/S3/04
Has Data Monitoring Committee No
U.S. FDA-regulated Product
Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
IPD Sharing Statement  ICMJE
Plan to Share IPD: No
Responsible Party Centre Hospitalier le Mans
Study Sponsor  ICMJE Centre Hospitalier le Mans
Collaborators  ICMJE Not Provided
Investigators  ICMJE
Principal Investigator: Nicolas Chudeau, MD Centre Hospitalier Le Mans, Intensive Care Unit
PRS Account Centre Hospitalier le Mans
Verification Date June 2019

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP