ECLS total de emergência versus ACLS padrão com resgate de ECMO para sobrevivência em OHCA refratário (ECLS-OHCA)
Suporte de vida extracorpóreo total de emergência versus suporte de vida cardíaco avançado padrão com resgate de ECMO para sobrevivência com resultado neurológico favorável em parada cardíaca extra-hospitalar refratária
The goal of the clinical trial is to learn if early extracorporeal life support ( ECLS ) will save more out-of-hospital cardiac arrest ( OHCA ) patients with good neurological outcome. It will also learn if emergency ECLS is safe in the OHCA rescue. Researchers aim to investigate if emergency total ECLS is better than standard advanced cardiac life support ( ACLS ) first, followed by bailout ECMO if required, for survival with favorable neurological outcome in OHCA patients. Participants meeting criteria of OHCA with witness, bystander CPR, shockable initial rhythm with repeated defibrillation, and transport time less than 30 min will be compared between total ECLS versus standard ACLS first with bailout ECMO protocols. All participants will receive emergency interventional coronary revascularization , intensive care unit therapy , cardiac ward care and up to 180 days of clinical follow up after survival .
Visão geral do estudo
Status
Condições
Intervenção / Tratamento
Descrição detalhada
Out-of-hospital cardiac arrest ( OHCA ) is a highly lethal emergency, unless return of spontaneous circulation ( ROSC ) is timely achieved by efficient and effective resuscitation. Nevertheless, despite advanced cardiopulmonary resuscitation ( CPR ) with mechanical chest compression, assisted ventilation and automatic external defibrillation, the survival of OHCA patients remains below 10%. Extracorporeal membranous oxygenation ( ECMO ) facilitated life support ( ECLS ) could help hemodynamic stability and improve significantly the survival of refractory OHCA to 25-40 %. On the other hand, the precise role and timing of the ECLS during the emergency management of OHCA remains largely unestablished.
In the present study, we hypothesized that emergency total ECLS is superior to standard ACLS with ECMO bailout for survival with favorable neurological outcome in refractory out-of-hospital cardiac arrest. All OHCA patients meeting the including criteria, i.e. age 18-75 years, witnessed cardiac arrest with bystander CPR, initial shockable rhythm as ventricular fibrillation or pulseless ventricular tachycardia ( VF/pVT ), repeated defibrillation shocks and escorted transportation within 30 minutes from 119 call to arriving emergency department ( ED ) in the hospital would be recruited. Eligible patients will be consecutively randomized at ED in 1:1 ratio, stratified by hospitals, into emergency total ECLS group and standard ACLS with ECMO bailout group. Informed consent is waived in the life-threatening emergency condition. For emergency total ECLS group, OHCA patients will receive early implantation and initiation of ECMO circulation within 15 minutes after randomization or up to 45 minutes after 119 call. For standard ACLS with ECMO bailout group, OHCA patients will receive standard ACLS for at least 45 minutes after collapse or 119 call or at least 15 minutes after ED arrival before calling for bailout ECMO if required. Following return of spontaneous systemic circulation (ROSC) or depending on ECMO circulation, both groups would be transferred to brain and chest computer tomography screening, emergency coronary revascularization intervention and subsequent intensive cardiac care with targeted hypothermia management. Survivals will be treated with guideline directed medical therapy for reduced ejection fraction heart failure and/or implantable cardioverter-defibrillator implantation for prevention of recurrent VT/VF in wards. All survivals will be followed up for medical and neurological status at 30 days, 90 days and 180 days after discharge.
Primary endpoint is survival with favorable neurological outcome at 30 days. Secondary endpoints are survival to discharge with favorable neurological outcome, survival with favorable neurological outcome at 180 days, total duration of cardiopulmonary resuscitation ( CPR ), total duration of mechanical ventilation, total duration of intensive care unit stay, total duration of hospitalization. Safety endpoints will be incidence of serious adverse events related to prolonged CPR, prolonged ischemia, and ECMO systemic perfusion and coronary reperfusion.
The number of subjects to be enrolled according to the primary endpoint of 30 days survival with favorable neurological outcome. With a power of 80%, accepting the level of statistical significance at alpha= 0.05 and based on two-sided Chi-Square test, we estimated 166 participants per arm are needed. This is based on the 30% success rate and 15% success rate of 30-day survival with good neurological outcome of emergency total ECLS intervention and standard ACLS with bailout ECMO (if required) intervention, according to previous trials, plus a 10% drop out rate. Based on two-tailed test, p less than 0.05 is considered statistical significance. If interim analysis is deemed necessary, the significance level will be adjusted accordingly using Bonferroni method. Because of no interim analysis and no stopping point in ITT protocol, there is no criteria for premature termination of the trial. The missing data of the primary and secondary efficacy outcomes will be considered as failure for ITT analysis. Last observations carry forward method will be adapted for the missing data of repeated measurements. The data record will be monitored and audited by the Institutional Review Board of the TMU Shuangho hospital as well as the Data and Safety Monitoring Plan committee.
Tipo de estudo
Inscrição (Estimado)
Estágio
- Não aplicável
Contactos e Locais
Contato de estudo
- Nome: Jiunn-Lee Lin, MD, PHD
- Número de telefone: 15313 +886-66202589
- E-mail: jiunnleelin@gmail.com
Locais de estudo
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Taiwan
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New Taipei, Taiwan, Taiwan, 23561
- Recrutamento
- Shuang Ho Hospital
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Contato:
- Jiunn-Lee Lin, MD, PHD
- Número de telefone: 886-905972029
- E-mail: jiunnlee@gmail.com
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Contato:
- Jiunn-Lee Lin, MD PHD
- Número de telefone: +886-905972029
- E-mail: jiunnleelin@gmail.com
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Contato:
- Cheng-Yu Huang, bachelor
- Número de telefone: +886-988986856
- E-mail: chengyuhuang2018@gmail.com
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Investigador principal:
- Jiunn-Lee Lin, MD PHD
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Critérios de participação
Critérios de elegibilidade
Idades elegíveis para estudo
Aceita Voluntários Saudáveis
Gêneros Elegíveis para o Estudo
Descrição
Inclusion Criteria:
- adults aged 18-75 years old
- witnessed cardiac arrest with bystander CPR
- initial shockable rhythm as ventricular fibrillation or pulseless ventricular tachycardia ( VF/pVT )
- repeated defibrillation shocks ( more than 2 ) by external defibrillator
- estimated transportation time from 119 call to arrival at emergency service less than 30 minutes.
Exclusion Criteria:
- age less than 18 years or more than 75 years old
- non-shockable initial rhythm, i.e. pulseless electrical activity or asystole
- acute aortic dissection
- acute massive pulmonary embolism
- intracerebral hemorrhage
- major trauma due to blunt, penetrating or burn injury
- severe peripheral artery occlusion disease
- known pregnancy
- suicide, illicit drug overdose or intoxication
- known pre-arrest modified Rankin score ( mRS ) more than 3 or cerebral performance category scale ( CPC ) more than 2
- severe concomitant malignancy with expected life expectancy less than 1 year
- signed and effective do-not-resuscitation ( DNR ) order
- absolute contraindications to emergency coronary angiography, including known anaphylactic reaction to angiographic contrast media, acute gastrointestinal bleeding or internal bleeding.
Plano de estudo
Como o estudo é projetado?
Detalhes do projeto
- Finalidade Principal: Tratamento
- Alocação: Randomizado
- Modelo Intervencional: Atribuição Paralela
- Mascaramento: Nenhum (rótulo aberto)
Armas e Intervenções
Grupo de Participantes / Braço |
Intervenção / Tratamento |
|---|---|
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Comparador Ativo: Total ECLS in refractory OHCA
Emergency total extracorporeal life support ( ECLS ) in cardiopulmonary resuscitation of OHCA patients with refractory ventricular fibrillation or pulseless ventricular tachycardia |
ECMO supported life support for cardiopulmonary resuscitation in refractory OHCA |
|
Comparador Ativo: standard ACLS in refractory OHCA
Emergency standard advanced cardiac life support ( ACLS ) in cardiopulmonary resuscitation of OHCA patients with refractory ventricular fibrillation or pulseless ventricular tachycardia. Bailout ECMO allowed after at least 45 minutes of CPR since collapse and 119 call or at least 15 minutes since arrival at emergency department |
Standard ACLS in cardioplumonary resuscitation of refractory OHCA |
O que o estudo está medindo?
Medidas de resultados primários
Medida de resultado |
Descrição da medida |
Prazo |
|---|---|---|
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The rate of survival with favorable neurological outcome ( modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) at 30 days after discharge from hospital, in percentage
Prazo: From randomization to 30 days after survival discharge from hospital
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After survival discharge from hospital, clinical followup at out-patient clinic or by visual phone interview is conducted to assess medical health status as well as neurological status of the patients at 30 days after discharge from hospital. Survival with favorable neurological outcome ( i.e. modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) is to be measured as percentage of all randomized patients fulfilling inclusion criteria and without any exclusion criteria. |
From randomization to 30 days after survival discharge from hospital
|
Medidas de resultados secundários
Medida de resultado |
Descrição da medida |
Prazo |
|---|---|---|
|
Total duration of cardioplumonary resuscitation from on-site CPR by EMS till the stable ROSC or initiation of ECMO life support or the decease of the subject at emergency department up to 30 days after randomization, in minutes
Prazo: From the start of on-site CPR by EMS till the return of stable ROSC or the initiation of ECMO life support or the decease of the subject at the emergency department up to 30 days after randomization, in minutes
|
total duration of standard cardiopulmonary resuscitation ( CPR ) is counted from the start of on-site CPR by emergency medical service ( EMS ) till the stable return of spontaneous circulation ( ROSC ) or initiation of ECMO life support or the decease of the subject at emergency department ( ED ) up to 30 days after randomization. The measure is in minutes. |
From the start of on-site CPR by EMS till the return of stable ROSC or the initiation of ECMO life support or the decease of the subject at the emergency department up to 30 days after randomization, in minutes
|
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The rate of survival with favorable neurological outcome ( modified Rankin score less than 3 or CPC scale 1 or 2 ) from the date of randomization to the date of discharge from hospital up to 180 days after randomization, in percentage
Prazo: From the date of randomization to the date of discharge from hospital up to 180 days after randomization, in percentage.
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At discharge from hospital, patient status is assessed as survival or mortality. The rate of survival with favorable neurological outcome ( modified Rankin score <3 or CPC scale 1 or 2 ) is counted from the date of randomization to the date of discharge from hospital up to 180 days after randomization. The rate of survival is measured as percentage of total randomization number. |
From the date of randomization to the date of discharge from hospital up to 180 days after randomization, in percentage.
|
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The rate of survival with favorable outcomes ( modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) at 90 days after discharge from hospital, in percentage
Prazo: From the date of randomization to 90 days after survival discharge from hospital
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After patients survived and discharged from hospital, clinical followup at out-patient clinic or by visual phone interview is conducted to assess medical health as well as neurological status at 90 days after discharge. The rate of survival with favorable neurological outcome ( i.e. modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) is measured as percentage of all randomized patients fulfilling inclusion criteria and without any exclusion criteria. |
From the date of randomization to 90 days after survival discharge from hospital
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The rate of survival with favorable outcomes ( modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) at 180 days, in percentage
Prazo: From enrollment to the end of treatment at 180 days
|
After patients discharged from hospital, clinical followup at out-patient clinic or by visual phone interview is conducted to assess medical health as well as neurological status at 180 days after discharge. The rate of survival with favorable neurological outcome ( i.e. modified Rankin score less than 3 or cerebral performance category scale 1 or 2 ) is measured as percentage of all enrolled patients fulfilling inclusion criteria and without any exclusion criteria. |
From enrollment to the end of treatment at 180 days
|
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total duration of mechanical ventilation from randomization to discharge from hospital or up to 180 days after randomization , in days
Prazo: From randomization at the emergency department to discharge from hospital or up to 180 days after randomization
|
The total duration of assisted mechanical ventilation by volume cycle or pressure cycled artificial ventilators from randomization at the emergency department to discharge from hospital or up to 180 days after randomization, measured in days. |
From randomization at the emergency department to discharge from hospital or up to 180 days after randomization
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total duration of stay in intensive care ward from randomization to discharge from hospital or up to 180 days after randomization , in days
Prazo: From the date of randomization to the date of discharge from hospital or up to 180 days after randomization
|
The total duration of stay in intensive care ward from randomization to discharge from hospital or up to 180 days after randomization. The intensive care ward is to provide cardiovascular hemodynamic support, assisted mechanical ventilation, targeted temperature therapy ( if needed ) and infection control, whenever needed. The measure is in days. |
From the date of randomization to the date of discharge from hospital or up to 180 days after randomization
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total duration of hospitalization from the date of randomization to the date of discharge or up to 180 days after randomization , in days
Prazo: From the date of randomization to the date of discharge from hospital or up to 180 days after randomization, survived or deceased.
|
total duration of stay in the hospital from the date randomization at emergency department to the date discharge from hospital or up to 180 days after randomization, survived or deceased. The measure in in days. |
From the date of randomization to the date of discharge from hospital or up to 180 days after randomization, survived or deceased.
|
Colaboradores e Investigadores
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Publicações e links úteis
Datas de registro do estudo
Datas Principais do Estudo
Início do estudo (Real)
Conclusão Primária (Estimado)
Conclusão do estudo (Estimado)
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Mais Informações
Termos relacionados a este estudo
Palavras-chave
Termos MeSH relevantes adicionais
- Doenças cardiovasculares
- Processos Patológicos
- Doenças cardíacas
- Morte
- Parada cardíaca
- Condições Patológicas, Sinais e Sintomas
- Parada Cardíaca Fora do Hospital
- Morte, Súbita
- Terapêutica
- Procedimentos cirúrgicos, operatórios
- Terapia respiratória
- Circulação extracorpórea
- Oxigenação por Membrana Extracorpórea
Outros números de identificação do estudo
- N202312122
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