- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT01120964
Intravenous L-Citrulline to Treat Children Undergoing Heart Bypass Surgery : Revised Protocol
Phase IB Double Blind, Randomized, Placebo Controlled Clinical Trial to Determine the Pharmacokinetics and Safety of a Revised Protocol of Intravenous L-Citrulline (Citrupress®) Versus Placebo in Children Undergoing Cardiopulmonary Bypass
This clinical trial will determine the safety and effectiveness of intravenous L-citrulline in children undergoing cardiopulmonary bypass during heart surgery. Participants will be randomly assigned to either L-citrulline or a placebo (a substance that has no medicine in it).
Citrulline is a protein building block in the body that can convert into another substance, nitric oxide (NO), which controls blood pressure in the lungs. Increased blood pressure in the lungs can be an important surgical problem; it may also lead to problems following surgery, such as severe high blood pressure in the lungs (pulmonary hypertension), increased time spent on a breathing machine, and a longer stay in the intensive care unit (ICU). The hypothesis of this study is that perioperative supplementation with intravenous citrulline will increase plasma citrulline, arginine and NO metabolites and prevent elevations in the postoperative PVT leading to a decrease in the duration of postoperative invasive mechanical ventilation.
The objective of this study is to determine in a randomized placebo controlled phase IB multicenter clinical trial if a revised protocol of intravenous L-citrulline delivery given perioperatively achieves a plasma citrulline level of > 100 umol/L in children undergoing surgical repair of an atrial septal defect,ventricular septal defect or an atrioventricular septal defect.
Study Overview
Status
Intervention / Treatment
Detailed Description
Study Type
Enrollment (Actual)
Phase
- Phase 2
- Phase 1
Contacts and Locations
Study Locations
-
-
Missouri
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Saint Louis, Missouri, United States, 63110
- Washington University Children's Hospital
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Ohio
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Cincinnati, Ohio, United States, 45229
- Cincinnati Children's Hospital Medical Center
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-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Informed Consent signed by the subject's legal representative
- Subjects < 6 years old
- Subjects undergoing cardiopulmonary bypass for repair of an atrial septal defect, a ventricular septal defect or an atrioventricular septal defect
Exclusion Criteria:
- Pulmonary artery or vein abnormalities being addressed surgically
- Preoperative requirement for invasive mechanical ventilation or intravenous inotrope support
- Any condition which, in the opinion of the investigator, might interfere with study objectives
Study Plan
How is the study designed?
Design Details
- Primary Purpose: PREVENTION
- Allocation: RANDOMIZED
- Interventional Model: PARALLEL
- Masking: SINGLE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
EXPERIMENTAL: Intravenous L-Citrulline
IV bolus of 150 mg/kg L-citrulline at the initiation of bypass, followed by L-citrulline (200 μmol/L) addition to the filtration or hemoconcentration replacement fluid used during bypass.
Plus L-citrulline (20 mg/kg) bolus 30 minutes after decannulation from bypass, immediately followed by 9 mg/kg/h continuous L-citrulline infusion for 48 hours.
|
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PLACEBO_COMPARATOR: Placebo of Intravenous L-Citrulline
Placebo administered according to the same schedule as L-citrulline
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Placebo of intravenous L-Citrulline given at the same prescribed times as L-Citrullne Drug
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
L-citrulline Plasma Levels
Time Frame: Measured in seven blood sample time points from the beginning of surgery until end of IV Citrulline Infusion; at either 48 hours postoperatively or at extubation, whichever comes first.
|
Citrulline Blood Levels: 1. Baseline sample in OR prior to Cardiopulmonary Bypass prior to administration of first bolus of Citrulline or Placebo 2. Immediately after Bolus 1 administered in Operating Room. 3. 30 minutes after separation from Cardiopulmonary Bypass; immediately prior to administration of Bolus 2 and start of continuous infusion of Citrulline or Placebo.
4. Six hours after after start of infusion.
5. 12 hours after start of infusion.
6. 24 hours after start of infusion.
7. 48 hours after start of infusion; or whenever infusion is discontinued if prior to 48 hours.
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Measured in seven blood sample time points from the beginning of surgery until end of IV Citrulline Infusion; at either 48 hours postoperatively or at extubation, whichever comes first.
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Postoperative Invasive Mechanical Ventilation (Mean and SD)
Time Frame: Measured in hours from the end of surgery until extubation, or Day 30, whichever occurs first
|
Duration of postoperative invasive mechanical ventilation was derived as the time in hours from separation from cardiopulmonary bypass until endotracheal extubation.
If a patient required reintubation within 24 hours after extubation, the reintubation time was added in the main analysis.
In a second analysis, the reintubation time was not included.
|
Measured in hours from the end of surgery until extubation, or Day 30, whichever occurs first
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Postoperative Invasive Mechanical Ventilation (Median and Range)
Time Frame: Measured in hours from the end of surgery until extubation or Day 30, whichever occurred first
|
Duration of postoperative invasive mechanical ventilation was derived as the time in hours from separation from cardiopulmonary bypass until endotracheal extubation.
If a patient required reintubation within 24 hours after extubation, the reintubation time was added in the main analysis.
In a second analysis, the reintubation time was not included.
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Measured in hours from the end of surgery until extubation or Day 30, whichever occurred first
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Total Duration of Respiratory Support
Time Frame: Baseline to discharge or Day 30, whichever occurs first
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Analysis included any invasive and non-invasive respiratory support required during the study period
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Baseline to discharge or Day 30, whichever occurs first
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Postoperative Intravenous Inotrope Duration
Time Frame: Measured at 48 hours
|
The length of time on IV inotropes was documented from the time of first use after surgery until completion of the study medication at Hour 48 (i.e., duration of inotrope use was maximally 48 hours).
Patients still receiving inotropes at Hour 48 were censored.
|
Measured at 48 hours
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Total Inotrope Score
Time Frame: PICU admission until Hour 48
|
The inotrope dose was calculated each hour postoperatively from the time of PICU admission until the completion of study drug using the following scoring system: Dopamine (μg/kg/min) x 1 plus Dobutamine (μg/kg/min) x 1 plus Milrinone (μg/kg/min) x10 plus Epinephrine (Adrenaline) (μg/kg/min) x 100 plus Phenylephrine (μg/kg/min) x 100 plus Norepinephrine (Noradrenaline) (μg/kg/min) x 100 = Total inotrope score An ANOVA was performed. Additionally a repeated measures analysis of variance was used to compare total inotrope score between placebo and citrulline. |
PICU admission until Hour 48
|
Time on Vasoactive Medications
Time Frame: Hour 0 to Hour 48
|
The total number of hours on vasoactive medications, including nitroglycerin, nitroprusside and vasopressin, was calculated from the end of surgery until the discontinuation of vasoactive medications or end of study medication (Hour 48), whichever occurred first
|
Hour 0 to Hour 48
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Total Vasoactive Score
Time Frame: Hour 0 to Hour 48
|
Vasoactive score is reflective of the pharmacological support required by the cardiovascular system and is a good predictor of mortality and morbidity in patients undergoing bypass surgery. A lower vasoactive score represents less pharmacological support and would indicate a lower risk for a poor clinical outcome. Therefore, any treatment effect would be indicated by a lower score in the citrulline group when compared to the placebo group. In this study, the score was calculated post-operatively from the time of separation from bypass until the completion of study drug. Vasoactive score was calculated using the following formula: Total Vasoactive Score = nitroglycerin dose + nitroprusside dose + vasopressin dose The minimum value is zero (i.e., no vasoactive drugs administered), but it is not possible to define a maximum as this is wholly dependent upon the dose of each vasoactive drug administered. |
Hour 0 to Hour 48
|
Length of ICU Stay
Time Frame: Measured in hours from the end of surgery to discharge from ICU or Day 30, whichever occurred first
|
Duration of ICU stay was analyzed once as the total number of postoperative hours spent in the ICU and once as the total number of postoperative hours that a patient required postoperative mechanical ventilator or continuous intravenous inotrope or vasodilator support.
The latter combination of parameters represents another surrogate endpoint for ICU stay
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Measured in hours from the end of surgery to discharge from ICU or Day 30, whichever occurred first
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Composite Endpoint: Cessation of Positive Pressure Ventilation and of Inotrope Therapy
Time Frame: Until cessation of positive pressure ventilation and of inotrope therapy or Day 30, whichever occurred first
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The composite endpoint comprised the longer of the duration of positive pressure ventilatory support or of inotrope therapy.
Since inotrope use was only documented until Hour 48 after surgery (end of study medication treatment), patients with inotrope use continuing until Hour 48 and with mechanical ventilation duration of ≤48 h were censored at this time point.
If mechanical ventilation was continued beyond the 48-hour time point, the duration of mechanical ventilation was used in the analysis.
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Until cessation of positive pressure ventilation and of inotrope therapy or Day 30, whichever occurred first
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Length of Hospitalization
Time Frame: Measured from the day of surgery until discharge from hospital or Day 30, whichever occurred first
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Measured from the day of surgery until discharge from hospital or Day 30, whichever occurred first
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Incidence of Increased PVT (Defined as a Sustained Mean Pulmonary Artery Pressure Greater Than 20 mm Hg for at Least 2 Hours, Measured During the First 48 Hours
Time Frame: Measured in hours from the end of surgery until extubation or Day 30, whichever occurred first
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There were insufficient data to analyze ECHO measurements in summary statistics.
Additionally, most images were of very low quality and the data from ECHO evaluations were insufficient to determine whether the affected patients had pulmonary hypertension.
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Measured in hours from the end of surgery until extubation or Day 30, whichever occurred first
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Duration of Chest Tube Drainage
Time Frame: Measured in hours from the end of surgery until removal of chest tubes or Day 30, whichever occurred first
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Measured in hours from the end of surgery until removal of chest tubes or Day 30, whichever occurred first
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Volume of Chest Tube Drainage
Time Frame: Measured in milliliters from the end of surgery until removal of chest tubes or Day 30, whichever occurred first
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Measured in milliliters from the end of surgery until removal of chest tubes or Day 30, whichever occurred first
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Survival
Time Frame: Measured at 28 days post surgical repair
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28-day postoperative survival and survival to discharge
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Measured at 28 days post surgical repair
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Number of Patients With Clinically Significant Hypotension.
Time Frame: Mean Arterial Blood pressure as continuously monitored postoperatively in the PCCU (Hour 0 to Hour 24) during Citrulline or Placebo infusion.
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Age specific mean arterial blood pressure (MAP) limits compared between the citrulline and placebo groups will be used to determine significant hypotension. Defined as MAP below a specific age-based value (infants and age 1 year, 40; ; age 2 years, 44; age 3 years, 47; age 4 years, 50; age 5 years, 52; age 6 years, 53), that lasted greater than 30 minutes and was unresponsive to therapeutic interventions such as fluid administration (volume bolus) and increasing inotropic support. |
Mean Arterial Blood pressure as continuously monitored postoperatively in the PCCU (Hour 0 to Hour 24) during Citrulline or Placebo infusion.
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Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Arginine Concentrations
Time Frame: Baseline to Hour 48
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Citrulline is the precursor of arginine and nitric oxide.
Nominal sampling times were Baseline, Post-bolus 1, Pre-bolus 2, and Hours 2, 6, 12, 24 and 48.
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Baseline to Hour 48
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Nitric Oxide Concentrations
Time Frame: Baseline to Hour 48
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Citrulline is the precursor of arginine and nitric oxide.
Nominal sampling times were Baseline, Post-bolus 1, Pre-bolus 2, and Hours 2, 6, 12, 24 and 48.
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Baseline to Hour 48
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Collaborators and Investigators
Sponsor
Investigators
- Study Chair: Frederick E Barr, MD, Batson Children's Hospital, University of Mississippi Medical Center
- Principal Investigator: Catherine Krawczeski, MD, Children's Hospital Medical Center, Cincinnati
- Principal Investigator: Allan Doctor, MD, St. Louis Children's Medical Center
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 (ACTUAL)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- CIT-002-01
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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