- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03003390
Catheter-Related Early Thromboprophylaxis With Enoxaparin (CRETE) Trial (CRETE)
July 10, 2020 updated by: Yale University
Prevention of Central Venous Catheter-associated Thrombosis in Critically Ill Children: A Multicenter Phase 2b Trial
The purpose of this phase 2a, multi-center, randomized controlled study, is to explore the efficacy of early prophylaxis against catheter-associated deep venous thrombosis (CADVT) in critically ill children.
Study Overview
Detailed Description
Critical illness and the presence of a central venous catheter (CVC) are the most important risk factors for deep venous thrombosis (DVT) in children.
Catheter-associated thrombosis (CADVT) is highly prevalent and associated with poor outcomes in critically ill children.
Yet, based on underpowered pediatric trials, prophylaxis against CADVT is not recommended in children.
The recommendation to provide prophylaxis against thrombosis in critically ill adults should not be applied to children because the hemostatic system and co-morbidities vastly differ between age groups.
Pivotal trials are urgently needed to determine whether prophylaxis can prevent CADVT and its complications in critically ill children.
However, the timing and extent of reduction in thrombin generation, the biochemical goal of prophylaxis, needed to prevent CADVT in children are unclear.
The goal of this application is to explore the efficacy of early prophylaxis against CADVT in critically ill children.
Aim 1 is to obtain preliminary evidence on the effect of early prophylaxis on the incidence of CADVT in critically ill children.
Based on the natural history of CADVT, we hypothesize that among critically ill children, prophylaxis administered <24 hours after catheter insertion decreases the incidence of ultrasound-diagnosed CADVT compared with no prophylaxis.
In this phase 2a trial, children admitted to the intensive care unit with a newly inserted central venous catheter will receive enoxaparin adjusted according to anti-Xa activity, a control group will not receive enoxaparin adjusted according to anti-Xa activity.
Enoxaparin has become the "standard" pediatric anticoagulant for prophylaxis despite the absence of conclusive data.
We will use Bayesian approach to determine whether further trials are warranted.
Aim 2 is to evaluate the effect of an anti-Xa activity-directed prophylactic strategy on thrombin generation in critically ill children.
We hypothesize that among critically ill children, standard prophylactic dose of enoxaparin adjusted by anti-Xa activity reduces thrombin generation to <700 nanomolar-minute (nM.min), as measured by endogenous thrombin potential (ETP).
In non-critically ill adults, prophylactic dose of enoxaparin proven to prevent DVT reduces ETP to <700 nM.min.
Endogenous thrombin potential is the best available measure of thrombin generation.
We will measure endogenous thrombin potential and anti-Xa activity at multiple time points then examine their relationship in all children enrolled in the phase 2a trial.
The proposed research challenges the current paradigm on prophylaxis against CADVT in children.
High quality evidence is needed to prevent CADVT and its complications in this vulnerable population.
Study Type
Interventional
Enrollment (Actual)
51
Phase
- Phase 2
Contacts and Locations
This section provides the contact details for those conducting the study, and information on where this study is being conducted.
Study Locations
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Connecticut
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New Haven, Connecticut, United States, 06520
- Yale University Yale New Haven Health
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Missouri
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Saint Louis, Missouri, United States, 63110
- Saint Louis Children's Hospital-Washington University School of Medicine-
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New York
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New York, New York, United States, 10065
- Weill Cornell Medicine
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Rochester, New York, United States, 14642
- University of Rochester Medical Center-Golisano Children's Hospital-
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Valhalla, New York, United States, 10595
- Maria Fareri Children's Hospital
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Wisconsin
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Milwaukee, Wisconsin, United States, 53226
- Children's Hospital of Wisconsin/Medical College of Wisconsin
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Participation Criteria
Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.
Eligibility Criteria
Ages Eligible for Study
No older than 17 years (CHILD)
Accepts Healthy Volunteers
No
Genders Eligible for Study
All
Description
Inclusion Criteria
- Untunneled CVC inserted in the internal jugular or femoral vein within the past 24 hours
- Child anticipated to stay in the pediatric intensive care unit ≥48 hours
- CVC anticipated to be required for ≥24 hours
- >36 weeks corrected gestational age to <18 years old
Exclusion Criteria
- Coagulopathy (i.e., international normalized ratio >2.0, activated partial thromboplastin time >50 seconds or platelet count <50,000/mm3)
- Known bleeding disorder
- Clinically relevant bleeding as defined by the International Society on Thrombosis and Hemostasis (i.e., Hb decreased ≥2 g/dl in 24 hours, required medical or surgical intervention to restore hemostasis, or in a critical organ system [i.e., retroperitoneum, pulmonary, intracranial or central nervous system])
- <60 days from a clinically relevant bleeding as defined above
- <7 days after trauma or surgery
- Anticipated surgery within 48 hours after insertion of the CVC
- Renal failure (i.e., creatinine clearance <30 mL/min)
- Presence of epidural catheter
- Currently taking an antithrombotic agent (e.g., low molecular weight heparin (LMWH), unfractionated heparin (UFH) at therapeutic doses, Coumadin or aspirin)
- Radiologically documented DVT at the site of insertion of the CVC in the previous 6 weeks
- Known hypersensitivity to heparin or its components, including pork products
- History of heparin-induced thrombocytopenia (HIT) (i.e., positive serotonin release assay)
- Currently pregnant
- Currently lactating
- Prior enrollment in the study
- Limitation of care
Study Plan
This section provides details of the study plan, including how the study is designed and what the study is measuring.
How is the study designed?
Design Details
- Primary Purpose: PREVENTION
- Allocation: RANDOMIZED
- Interventional Model: PARALLEL
- Masking: NONE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
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EXPERIMENTAL: Prophylaxis with enoxaparin
A clinical nurse will administer enoxaparin subcutaneously <24 hours after insertion of the central venous catheter and then give enoxaparin subcutaneously every 12 hours until the removal of the catheter.
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The clinical nurse will give enoxaparin subcutaneously every 12 hours at the currently used starting dose of 0.75 mg/kg for children ≤2 months old or 0.5 mg/kg (maximum of 40 mg) for older children.
The 1st dose will be given <24 hours after insertion of the catheter.
Doses will be adjusted to target an anti-Xa level of 0.2-0.5 IU/mL.
Other Names:
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NO_INTERVENTION: Control arm
Participants randomized to the control arm will receive no 'placebo' intervention.
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Number of Participants With Central Venous Catheter (CVC)- Associated Deep Vein Thrombosis (DVT)
Time Frame: Up to removal of CVC, an average of 6 days
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Thrombus in the central vein where the CVC was inserted that is clinically suspected then confirmed radiologically, an incidental radiologic finding, or diagnosed with the study-related active surveillance ultrasound
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Up to removal of CVC, an average of 6 days
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Endogenous Thrombin Potential
Time Frame: Day of, day after and day 4 after insertion of the CVC
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An established measure of coagulation status and is the best method to measure thrombin generation.
It directly measures the amount of thrombin generation over time capturing the effects of natural (i.e., subject's coagulation status) and pharmacological (e.g., enoxaparin) pro- and anticoagulants.
Endogenous thrombin potential is measured using thrombin generation assay.
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Day of, day after and day 4 after insertion of the CVC
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Number With Other Thromboembolic Events
Time Frame: Up to removal of CVC, an average of 6 days
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Thrombus in the deep vein of any extremity or PE that is clinically suspected then confirmed radiologically, an incidental radiologic finding, excluding DVT diagnosed with the study-related active surveillance ultrasound
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Up to removal of CVC, an average of 6 days
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Length of Stay in the Pediatric Intensive Care Unit in Days
Time Frame: Up to day of discharge from the pediatric intensive care unit, an average of 10 days
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Duration of stay in the pediatric intensive care unit from the day of enrollment
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Up to day of discharge from the pediatric intensive care unit, an average of 10 days
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Length of Stay in the Hospital
Time Frame: Up to day of discharge from the hospital, an average of 18 days
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Duration of stay in the hospital from the day of enrollment
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Up to day of discharge from the hospital, an average of 18 days
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Number With Clinically Relevant Bleeding
Time Frame: Up to 30 hours after the last enoxaparin dose
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Bleeding that is fatal, associated with a decrease in hemoglobin by ≥2 g/dl in 24 hours, requires medical or surgical intervention to restore hemostasis, or is in the retroperitoneum, pulmonary, intracranial or central nervous system as defined by International Society of Thrombosis and Haemostasis
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Up to 30 hours after the last enoxaparin dose
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Number With Laboratory Confirmed Heparin-induced Thrombocytopenia
Time Frame: Up to removal of CVC, an average of 6 days
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Heparin-induced thrombocytopenia that is diagnosed with a positive serotonin release assay
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Up to removal of CVC, an average of 6 days
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Number of Mortality
Time Frame: Up to day of discharge from the hospital, average of 18 days
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In-hospital mortality during the subject's admission
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Up to day of discharge from the hospital, average of 18 days
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Number of Enrolled Eligible Children
Time Frame: Up to 24 hours after insertion of CVC
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Number of eligible children enrolled in the study.
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Up to 24 hours after insertion of CVC
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Time to 1st Dose of Enoxaparin
Time Frame: Up to 48 hours after insertion of CVC
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Time to first dose of enoxaparin
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Up to 48 hours after insertion of CVC
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Time to Target Anti-Xa Activity
Time Frame: Up to removal of CVC, an average of 6 days
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Time from insertion of the CVC to time that anti-Xa activity was within 0.2-0.5 IU/mL.
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Up to removal of CVC, an average of 6 days
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Number of Missed Doses of Enoxaparin
Time Frame: Up to removal of CVC, an average of 6 days
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Number of doses of enoxaparin that were not administered.
This outcome measure was only applicable to the enoxaparin arm.
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Up to removal of CVC, an average of 6 days
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Number of Children With Ultrasound
Time Frame: Up to 24 hours after removal of CVC
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Number of children in whom ultrasound was not performed.
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Up to 24 hours after removal of CVC
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Collaborators and Investigators
This is where you will find people and organizations involved with this study.
Sponsor
Collaborators
Investigators
- Principal Investigator: E. Vincent S Faustino, MD, MHS, Associate Professor of Pediatrics, Yale School of Medicine
Publications and helpful links
The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.
General Publications
- Faustino EVS, Raffini LJ, Hanson SJ, Cholette JM, Pinto MG, Li S, Kandil SB, Nellis ME, Shabanova V, Silva CT, Tala JA, McPartland T, Spinella PC; CRETE Trial Investigators and the Pediatric Critical Care Blood Research Network (BloodNet) of the Pediatric Acute Lung Injury and Sepsis Investigators Network (PALISI); CRETE Trial Investigators: Clinical Coordinating Center:; and; Data Coordinating Center:; and; Outcomes Adjudication Committee:; and; Data and Safety Monitoring Board:; and; Independent Safety Monitor:; and; Children's Hospital Wisconsin:; and; Dell Children's Medical Center:; and; Maria Fareri Children's Hospital:; and; St. Louis Children's Hospital:; and; University of Rochester Golisano Children's Hospital:; and; Weill Cornell Medical Center:; and; Yale-New Haven Children's Hospital:; and; CRETE Trial Investigators and the Pediatric Critical Care Blood Research Network (BloodNet) of the Pediatric Acute Lung Injury and Sepsis Investigators Network (PALISI) and CRETE Trial Investigators: Clinical Coordinating Center: and and and Data Coordinating Center: and and and Outcomes Adjudication Committee: and and and Data and Safety Monitoring Board: and and and Independent Safety Monitor: and and and Children's Hospital Wisconsin: and and and Dell Children's Medical Center: and and and Maria Fareri Children's Hospital: and and and St. Louis Children's Hospital: and and and University of Rochester Golisano Children's Hospital: and and and Weill Cornell Medical Center: and and and and Yale-New Haven Children's Hospital: and and. Age-Dependent Heterogeneity in the Efficacy of Prophylaxis With Enoxaparin Against Catheter-Associated Thrombosis in Critically Ill Children: A Post Hoc Analysis of a Bayesian Phase 2b Randomized Clinical Trial. Crit Care Med. 2021 Apr 1;49(4):e369-e380. doi: 10.1097/CCM.0000000000004848.
- Faustino EVS, Shabanova V, Raffini LJ, Kandil SB, Li S, Pinto MG, Cholette JM, Hanson SJ, Nellis ME, Silva CT, Chima R, Sharathkumar A, Thomas KA, McPartland T, Tala JA, Spinella PC; CRETE Trial Investigators and the Pediatric Critical Care Blood Research Network (BloodNet) of the Pediatric Acute Lung Injury and Sepsis Investigators Network (PALISI). Efficacy of Early Prophylaxis Against Catheter-Associated Thrombosis in Critically Ill Children: A Bayesian Phase 2b Randomized Clinical Trial. Crit Care Med. 2021 Mar 1;49(3):e235-e246. doi: 10.1097/CCM.0000000000004784.
Study record dates
These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.
Study Major Dates
Study Start (ACTUAL)
April 5, 2017
Primary Completion (ACTUAL)
August 16, 2019
Study Completion (ACTUAL)
August 16, 2019
Study Registration Dates
First Submitted
December 19, 2016
First Submitted That Met QC Criteria
December 21, 2016
First Posted (ESTIMATE)
December 28, 2016
Study Record Updates
Last Update Posted (ACTUAL)
July 13, 2020
Last Update Submitted That Met QC Criteria
July 10, 2020
Last Verified
March 1, 2020
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- 1302011506
- 1R21HD089131-01A1 (NIH)
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Yes
Studies a U.S. FDA-regulated device product
No
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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