- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT00615381
Supraphysiologic Insulin to Improve Outcomes After Surgical Treatment of Unruptured Cerebral Aneurysms
Clinical Trial of Euglycemia Maintenance With Supraphysiologic Insulin vs Conventional Intensive Insulin Therapy to Improve Outcomes (Neurologic, Neuropsychiatric, and Biomarkers) After Surgical Treatment of Unruptured Cerebral Aneurysms
Study Overview
Detailed Description
PREOPERATIVE NEUROPSYCHIATRIC & NEUROLOGIC TESTING Up to thirty days before the scheduled elective surgical repair of his or her intracranial aneurysm, each patient will undergo neuropsychological examination by a neuropsychologist or psychometrician and assessment of neurologic status by a research nurse or the neurosurgical attending from the Department of Neurological Surgery.
The battery of neuropsychological tests will include the following:
- Benton Visual Retention Test
- Controlled Oral Word Association
- Rey-Osterrieth Complex Figure Copy
- Grooved Pegboard
- Trial Making Test
- Hopkins Verbal Learning Test
The assessment of neurologic status and the time to administer each assessment is as follows:
- Glasgow Outcome Scale (2 minutes)
- Modified Rankin Disability Scale (5 minutes)
- NIH Stroke Scale (2 minutes)
ANESTHETIC MANAGEMENT
Because of the possible effects of various anesthetic agents on immune function (in vitro and in vivo), all patients will undergo a standardized anesthetic:
- Premedication with 0- 0.03 mg/kg midazolam
- Induction of anesthesia with 0.05-0.5 mcg/kg/min remifentanil, 1-2 mg/kg propofol, and 0.6-1.2 mg/kg rocuronium
- Maintenance with 0.5-0.7 MAC desflurane and 0.05-1.0 mcg/kg/min remifentanil with rocuronium 0.1-0.2 mg/kg to maintain adequate neuromuscular blockade. FIO2 = 1.0±0.1
- Maintenance of core temperature 36.0±0.5°C
- Propofol 50-200 mcg/kg/min to produce an EEG burst suppression ratio of 0.7-0.8 immediately before temporary occlusion of the feeding artery proximal to the intracranial aneurysm (to increase the length of time that focal ischemia is tolerated)
- 2 mcg/kg fentanyl upon placement of the last dural stitch
- discontinuation of desflurane and remifentanil upon removal of the head from the Mayfield head fixation
- Postoperative analgesia with 0.2 mg dilaudid every 15 minutes, PRN
- Antiemetic rescue with 4 mg odansetron (no standard prophylaxis)
Additional standard care & standardized therapeutics/medications are as follows:
- Dexamethasone 10 mg after tracheal intubation followed by 4 mg every 4 hours for 48 hours
- Mannitol 0.5-1 g/kg after completion of positioning, if requested by surgeon
- Maintenance intravenous fluids ("4-2-1" rule) with 0.9% NaCl up to 20 mL/kg
- Replacement of blood loss with 6% Hetastarch (1 mL : 1 mL) up to 1000 mL followed by 5% Albumin (1 mL : 1mL) up to 2500 mL
- Nicardipine (5-15 mg/hr) ± Labetolol (5-50 mg) to keep systolic blood pressure ≤ 140 mmHg
- Phenylephrine (10-100 mcg/min) titrated to keep systolic blood pressure ≥ 90 mmHg
- Glycopyrollate (0.2 mg every 5 minutes) titrated to keep heart rate > 50 beats per minute
RANDOMIZATION On the day of surgery, after confirming entry into the study (i.e., confirmation of research consent and confirmation of completion of preoperative neuropsychiatric and neurologic testing), each patient will be randomly assigned to a specific protocol-Supraphysiologic Insulin vs. Normal Insulin (Appendix 1).
Randomization will be performed in blocks of 10 using a computer generated random number assignment (odd numbers = Supraphysiologic Insulin and even numbers = Normal Insulin)
MAINTENANCE OF EUGLYCEMIA Intraoperative blood glucose levels will be maintained in the target range of 80-110 mg/dL (euglycemia) using the randomly assigned protocol, as outline in Appendix 1. Blood glucose levels, insulin boluses and infusion rates, and dextrose infusion rates will be recorded on the Intraoperative Insulin & Glucose data sheet (Appendix 2).
Postoperative blood glucose levels will be maintained in the target range (80-110 mg/dL) using the standard intensive care unit protocol (Appendix 3).
PERIOPERATIVE SYSTEMIC INFLAMMATORY RESPONSE
Blood samples for serum protein analysis will be taken from the patient at the following times:
- With the placement of the arterial line (baseline)
- Every 4 hours after the surgical incision for 12 hours
- 24 and 48 hours after surgical incision
When possible, the blood samples will be taken from an arterial line that is placed routinely for perioperative care. One-half (approximately 1/2) tablespoon (7 mL) of blood will be taken for plasma protein analysis at each sampling time-a total of 6 samples (approximately 3 tablespoons or 42 mL of blood) will be collected during the first 48 hours.
POSTOPERATIVE NEUROPSYCHIATRIC & NEUROLOGIC TESTING Seven days (or on discharge from the hospital) and ninety days (± 14 days) after surgery, all patients will undergo the same battery of neuropsychiatric and neurologic tests that were administered preoperatively. In addition, the SF-36 questionnaire will be administered at these times to assess the patients' sense of functional ability. Twelve months (± 30 days) after surgery, patients will be interviewed in the neurosurgeon's office or telephoned to assess neurologic recovery (using the same battery of neurologic tests administered preoperatively and the SF-36).
Study Type
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
Illinois
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Chicago, Illinois, United States, 60611
- Northwestern Memorial Hospital
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-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Unruptured intracranial aneurysm
Exclusion Criteria:
- Diabetes
- Pregnancy
- Age less than 18 years
- Inability to undergo preoperative neuropsychiatric and neurologic functional testing
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Triple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Active Comparator: Normal insulin
Maintenance of intraoperative euglycemia (blood glucose 80--110 mg/dL) using normal intensive insulin infusion rates (0-10 U/hr).
|
insulin infusion (0-10 U/hr) vs. 0.3 U/kg/hr and boluses (0-8 U) adjusted every 15 minutes during the intraoperative period to maintain intraoperative euglycemia (blood glucose levels 80-120 mg/dL)
Other Names:
|
Experimental: Supraphysiologic insulin
Maintenance of intraoperative euglycemia (blood glucose 80--110 mg/dL) using supraphysiologic insulin infusion doses (0.3 U/kg/hr) and exogenous dextrose to provide stable blood glucose levels .
|
insulin infusion (0-10 U/hr) vs. 0.3 U/kg/hr and boluses (0-8 U) adjusted every 15 minutes during the intraoperative period to maintain intraoperative euglycemia (blood glucose levels 80-120 mg/dL)
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Time Frame |
---|---|
Neurologic Outcome--"poor" vs. "good." A "poor" outcome is assigned if the patient who arrived independently from home is discharged to a nursing home or rehabilitation hospital or dies.
Time Frame: Discharge from hospital after surgery
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Discharge from hospital after surgery
|
Secondary Outcome Measures
Outcome Measure |
Time Frame |
---|---|
Neuropsychiatric outcomes
Time Frame: Postoperative day 7, 90+/- 14 days, and 365+/-30 days
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Postoperative day 7, 90+/- 14 days, and 365+/-30 days
|
Neurologic Status (Glasgow Outcome Scale <=4; Modified Rankin Disability Scale >=2, NIH Stroke Scale <=10)
Time Frame: Postoperative day 7, 90+/- 14 days, and 365+/-30 days
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Postoperative day 7, 90+/- 14 days, and 365+/-30 days
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Amount of time blood glucose concentration is outside the target glucose concentration range (80-120 mg/dL)
Time Frame: Perioperative Period (Induction of anesthesia + 24 hrs)
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Perioperative Period (Induction of anesthesia + 24 hrs)
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Biomarkers of the Perioperative Inflammatory Response
Time Frame: Perioperative Period (Induction of anesthesia + 48 hrs)
|
Perioperative Period (Induction of anesthesia + 48 hrs)
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Dhanesh K. Gupta, M.D., Northwestern University Feinberg School of Medicine
Study record dates
Study Major Dates
Study Start
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Estimate)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- DKG 2498-002
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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