Comparison of Extubation Delay After Prolonged Sedation (ISOREA)

• ClinicalTrials.gov Identifier: NCT04710914
• Recruitment Status: Recruiting
• First Posted: January 15, 2021
• Last Update Posted: January 15, 2021
• Sponsor: University Hospital, Rouen
• Information provided by (Responsible Party): University Hospital, Rouen

Study Description

Brief Summary:

This monocentric, prospective, controlled, randomized, single-blind study will be conducted in surgical resuscitation at the Rouen University Hospital. The aim of our research project is to evaluate the extubation time after sedation with inhaled isoflurane compared to conventional intravenous sedation with midazolam, in patients who require prolonged sedation (3 to 28 days) in a context of septic shock. This population is particularly at risk of hypnotic accumulation due to the prolonged duration of use and the increased risk of developing renal or hepatic impairment in connection with septic shock.

Based on data from the literature on shorter durations of up to 96 hours of sedation, the investigators expect a decrease in the time to extubation in patients sedated with isoflurane as well as a better quality of awakening with a decrease in resuscitation delirium. This shortened duration of mechanical ventilation could have beneficial effects on the morbidity associated with prolonged sedation and ventilation: reduction of pneumopathies acquired under mechanical ventilation, reduction of the length of stay in resuscitation and hospitalization.

Condition or disease	Intervention/treatment	Phase
Septic Shock	Drug: Prolonged sedation with isoflurane; Drug: Prolonged sedation with midazolam	Phase 4

Detailed Description:

In intensive care, sedation of patients is frequently used for their management. Combined with analgesia, it provides the comfort essential for the implementation of certain therapies such as mechanical ventilation.

Classically, sedation is based on the combination of a hypnotic and an injectable morphine, most often midazolam and sufentanil. Midazolam is a benzodiazepine with many advantages: few hemodynamic effects, no limited duration of use and good workability. However, its use presents several difficulties in resuscitation:

1. Some patients have accelerated metabolism and resistance to benzodiazepines, either through chronic use of psychotropic or narcotic drugs. These patients develop tolerance phenomena due to enzyme induction. This tachyphylaxis leads to an increased need for midazolam to achieve the therapeutic goal.
2. Some pathologies, such as ARDS, require deep sedation in the initial phase, which may last several days. After this phase, prolonged sedation may be necessary before achieving sufficient improvement to allow sedation to be stopped.
3. The metabolism of midazolam is dependent on liver function and its elimination from renal function. Alteration of these functions, common in resuscitation, results in impaired elimination with accumulation of midazolam and 2 active metabolites, 1-hydroxy-midazolam and 1-hydroxy-midazolam-glucuronide.

These three difficulties may lead to an undesirable prolongation of the sedation period beyond the cessation of midazolam infusion, which is associated with an increase in morbidity such as neuromyopathies, ventilator-associated pneumopathies (VAPP), deliriums and withdrawal syndromes. These complications increase the length of stay and mortality in intensive care units.

For 30 years there has been a growing interest in the use of sedation in resuscitation with volatile halogenated agents (VHAs). These agents, administered by inhalation, have many advantages: short onset of action, good workability, effect not dependent on renal or hepatic function, almost exclusive and predictable respiratory elimination, absence of tachyphylaxis and metabolism not sensitive to enzyme induction. For these reasons, AVHs are widely used in anesthesia in the operating room. The hypnotic action of HVAs is closely correlated with the expired fraction of HVAs. Measured by gas analysers, it allows precise monitoring of the therapeutic effect. In contrast to resuscitation ventilators, all anesthesia ventilators are equipped with evaporation tanks and administration circuits, gas analyzers and associated facilities for their disposal. These technical constraints mean that, despite their many theoretical advantages, AVHs have not been used in resuscitation area.

In the early 2000s, a new device made it possible to use AVH in intensive care: the AnaConDa® system. It made it possible to administer AVH using an evaporator inserted into the patient circuit at the intubation catheter, completely independent of the ventilator. However, this device had several shortcomings in terms of user safety and cost due to the short service life of the consumables.

Since 2016, a new device is available in France: the MIRUS® (Pall Medical, Dreieich, Germany). It has several advantages over AnaConDa® :

• It is equipped with an integrated gas analyzer that allows the automatic adjustment of the AVH flow rate for a concentration target (FeAVH target). This results in greater safety and AVH savings,
• For each AVH with an MA (isoflurane, sevoflurane or desflurane), there is a MIRUS controller with a tank model with a coding and color-coding system to avoid medication errors,
• Filters and reflectors can be used for several days, thus reducing the cost of use.

Among the recent AVHs and as for its use in anesthesia, isoflurane has shown a safety of use in resuscitation on longer uses up to 96 hours without side effects. A recent retrospective study showed no excess mortality after prolonged use of isoflurane (minimum 96 hours, average 506 hours) in post-operative, mainly digestive surgery in patients with sepsis with an average age of 71 years. After medium-length sedation (average duration 52 hours, maximum 96 hours), the recovery and extubation times are shorter than with intravenous sedation with midazolam: 10 minutes versus 250 minutes for the extubation time, but with significant differences in sedation and analgesia protocol compared to our practices. The AVHs have moreover been included in the German recommendations on sedation in resuscitation.

This monocentric, prospective, controlled, randomized, single-blind study will be conducted in surgical resuscitation at the Rouen University Hospital. The aim of our research project is to evaluate the time to extubation after sedation with inhaled isoflurane compared to conventional intravenous sedation with midazolam, in patients requiring prolonged sedation (3 to 28 days) in a context of septic shock. This population is particularly at risk of hypnotic accumulation due to the prolonged duration of use and the increased risk of developing renal or hepatic impairment in connection with septic shock.

Based on data from the literature on shorter durations of up to 96 hours of sedation, the investigators expect a decrease in the time to extubation in patients sedated with isoflurane as well as a better quality of awakening with a decrease in resuscitation delirium. This shortened duration of mechanical ventilation could have beneficial effects on the morbidity associated with prolonged sedation and ventilation: reduction of pneumopathies acquired under mechanical ventilation, reduction of the length of stay in resuscitation and hospitalization.

Study Design

• Study Type: Interventional (Clinical Trial)
• Estimated Enrollment: 59 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: Single (Participant)
• Primary Purpose: Treatment
• Official Title: Comparison of Extubation Delay After Prolonged Sedation With Inhaled Isoflurane Using the MIRUS® Device or Continuous Intravenous Midazolam in Patients With Septic Shock in Intensive Care
• Actual Study Start Date: December 15, 2020
• Estimated Primary Completion Date: March 31, 2023
• Estimated Study Completion Date: March 31, 2023

Arms and Interventions

Arm	Intervention/treatment
Experimental: sedation by inhaled isoflurane; sedation by midazolam with the MIRUS device	Drug: Prolonged sedation with isoflurane; Adult patients admitted to the surgical intensive care unit at the Rouen University Hospital for septic shock and requiring sedation for more than 3 days and a maximum of 10 days will be randomised in two groups. The experimental group will receive sedation by inhaled isoflurane The control group will receive sedation by intravenous midazolam
Active Comparator: sedation with intravenous midazolam; continuation of sedation with intravenous midazolam	Drug: Prolonged sedation with midazolam; Adult patients admitted to the surgical intensive care unit at the Rouen University Hospital for septic shock and requiring sedation for more than 3 days and a maximum of 10 days will be randomised in two groups. The experimental group will receive sedation by inhaled isoflurane The control group will receive sedation by intravenous midazolam

Outcome Measures

Primary Outcome Measures :

1. The delay between the first sedation stop and extubation [ Time Frame: 10 days ]
   The delay between the first sedation stop and extubation. This time will be measured from the first interruption of sedation to the patient's extubation. If the patient needs to be resedated prior to extubation, the stop of sedation for the primary endpoint measurement will be the first stop of sedation.

Secondary Outcome Measures :

1. Wake-up time [ Time Frame: 10 days ]
   Measurement of the wake-up time defined by the time between stopping sedation and obtaining a RASS (Richmond Agitation and Sedation Scale) sedation level equal to 0%
2. Total duration of sedation and mechanical ventilation [ Time Frame: 90 days ]
   Total duration of sedation and mechanical ventilation: data obtained by the ICCA information system (IntelliSpace Critical Care and Anesthesia, Philips) allowing prescription and monitoring in surgical resuscitation.
3. Total duration of intensive care and hospital stay [ Time Frame: 90 days ]
   Total duration of intensive care and hospital stay: collection of hospitalization records
4. A measure of overall survival at 90 days defined by the duration between the inclusion date and the date of death. [ Time Frame: 90 days ]
   A measure of overall survival at 90 days defined by the duration between the inclusion date and the date of death. Use of the CDP2 software to consult hospitalization reports and telephone calls from the patient or his or her family in the event of missing data.
5. Measurement of wake-up time defined by the duration between the day of the first sedation stop and a RASS score of 0, [ Time Frame: 10 days ]
   duration between the day of the first sedation stop and a RASS score of 0between the day of the first sedation stop and a RASS score of 0,
6. Security [ Time Frame: 90 days ]
   Collection of intercurrent events
7. Doses of vasopressor, hypnotic and morphine amines administrated [ Time Frame: 3 days ]
   These data are available in the computerized prescriptions. The doses of hypnotics over the entire sedation period will be retrieved in the prescriptions for the midazolam group and extracted from the MIRUS controller using software provided by the manufacturer for the isoflurane group.
8. Measurement of the number of days without mechanical ventilation [ Time Frame: 90 days ]
   Measurement of the number of days without mechanical ventilation
9. Measurement of midazolam and 2 active metabolites, 1-OHM and 1-OHMG [ Time Frame: 24, 48 and 96 hours ]
   Quantitative blood assays of midazolam and 2 active metabolites, 1-OHM and 1-OHMG, performed for all patients at randomization, at sedation cessation and after sedation cessation.
10. Costs of sedative treatments (midazolam and isoflurane) and the devices needed to administer them (syringes and tubing for midazolam, reflector and filter exchanger for isoflurane) [ Time Frame: 90 days ]
    Costs of sedative treatments (midazolam and isoflurane) and the devices needed to administer them (syringes and tubing for midazolam, reflector and filter exchanger for isoflurane)

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

• Major patients,
• Sedated with midazolam and sufentanil for a maximum of 3 days and ventilated invasively,
• Presenting a duration of sedation and invasive ventilation expected after inclusion between 3 days and 10 days,

• Presenting septic shock according to the SEPSIS-3 definition with the following 4 criteria :

  • Clinical suspicion of infection or positive microbiological sample if applicable,
  • Organ Failure: SOFA (Sepsis-related Organ Failure Assessment) ≥ 2 (Annex n°5),
  • Need for vasoactive amines to maintain sufficient organ perfusion pressure,
  • Arterial lactate > 2mmol/l,
• Stabilized septic shock without the need to increase noradrenaline doses over the last 6 hours,
• For women, absence of current pregnancy: negative pregnancy test,
• Subjects affiliated to a social security system.
• If the patient is unable to sign the consent (emergency situation) the consent will be signed by his or her representative ((1) the trusted person, or failing that, (2) a family member, or (3) a relative of the person concerned). In this case, the patient will subsequently be asked for consent to continue the study.

Exclusion Criteria:

• Refusal of the patient to continue the study after waking up,
• Duration of sedation after randomization less than 3 days or more than 10 days.

Contacts and Locations

Contacts

Contact: Nell Marty, PhD; (33) 02 32 88 82 65; Nell.Marty@chu-rouen.fr

Locations

France

Rouen University Hospital; Recruiting

Rouen, France, 760031

Contact: Antoine LEFEVRE-SCELLES, Doctor (33) 02 32 88 17 01

Sponsors and Collaborators

University Hospital, Rouen

Investigators

• Principal Investigator: Antoine LEFEVRE-SCELLES, Doctor; CHU de Rouen

More Information

• Responsible Party: University Hospital, Rouen
• ClinicalTrials.gov Identifier: NCT04710914
• Other Study ID Numbers: 2018/0348/HP
• First Posted: January 15, 2021
• Last Update Posted: January 15, 2021
• Last Verified: January 2021

• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No

Additional relevant MeSH terms:

Shock, Septic; Shock; Pathologic Processes; Sepsis; Infections; Systemic Inflammatory Response Syndrome; Inflammation; Midazolam; Isoflurane; Adjuvants, Anesthesia; Hypnotics and Sedatives; Central Nervous System Depressants; Physiological Effects of Drugs; Anti-Anxiety Agents; Tranquilizing Agents; Psychotropic Drugs; Anesthetics, Intravenous; Anesthetics, General; Anesthetics; GABA Modulators; GABA Agents; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Anesthetics, Inhalation