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| Name | Class |
|---|---|
| CRDF Global | OTHER |
| Osypka Germany | UNKNOWN |
| Dalim BioTech Co., Ltd. | INDUSTRY |
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A condition of decreased serum T3 level in children after cardiac surgery using cardiopulmonary bypass has been commonly recognized as euthyroid sick syndrome (ESS). This syndrome has been closely associated with low cardiac output syndrome after heart surgery. The unique characteristics of pediatric patients with congenital heart disease (CHD) in Indonesia have caused ESS to arise in the population even before surgical managements. Thyroid hormones increase cardiac function, respiration and diuresis. Increased myocardial function occurred through the improvement of mitochondrial effectiveness as the body energy source by utilizing effective energy substrates, lactate and pyruvate. Prevention of decreased serum thyroid hormones level by T3 supplementation could be clinically beneficial. Intravenous T3 unit dose is very expensive and inapplicable for daily use. In adult studies, oral T3 was found to be effective for the prevention of decreased serum T3 levels; similar study on pediatric population, however, has not been elucidated.
Methods:
The study was conducted at the cardiac paediatric cardiac intensive care unit of National Cardiovascular Center Harapan Kita. It was performed on paediatric congenital heart disease population who underwent open heart surgery with randomised, double-blind, controlled trial design. All patients with congenital heart disease, 3 years old or less, were included. Types of congenital heart disease suffered required subject to undergo surgery using cardiopulmonary bypass machine with Aristotle score of 6-9. Surgery was aimed for biventricular repair.
The sample size needed almost 200 patients with 50% is in the treatment group. This calculation was based on 90% of patients will be extubated and expected hazard ratio of corresponding treatment group is 1.7 with 5% alpha error and 20% beta error.
Patients were randomised using block randomisation procedure. The stratification factor will be age at the time of recruitment: < 6 weeks old, 6 weeks - 5 months old, > 5 months - 3 years old. Randomization will occur on the day of surgery.
The placebo - saccharum lactis - OR oral T3 (Tetronine, Dalim Biotech Korea) with the dose of 1 mcg per kg body weight were administered via nasogastric tube for every 6 hours starting from the time of anaesthesia induction until 11 doses in total (60 hours after the initial administration). Serial free T3 (FT3) and thyroid stimulating hormone (TSH) measurement were performed starting from the induction of anaesthesia until patient's discharge. Haemodynamics monitoring and echocardiography evaluation was conducted from day 1 to 3 after the surgery.
Statistical analysis:
Primary analysis will be performed using Cox Proportional Hazards for time to extubation result, including terms for stratification factors (age, Aristotle score and nutrition status). Patients will be included in analysis if they were randomised and received at least one dose of study drug according to the principal of Intention-to-Treat (ITT).
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Oral triiodothyronine | Experimental | Oral T3 (triiodothyronine) is given 1 mcg/kg every 6 hourly through naso-gastric tube since induction of anaesthesia for 60 hours |
|
| Placebo | Placebo Comparator | Placebo (saccharin lactic) is given every 6 hourly through naso-gastric tube since induction of anaesthesia for 60 hours |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Oral triiodothyronine | Drug | Oral triiodothyronine is given peri-operatively through naso-gastric tube |
|
| Measure | Description | Time Frame |
|---|---|---|
| Intubation time | All patients after undergoing congenital heart surgery will be supported by mechanical ventilation. Duration of this support since cross clamp off removal until after surgery will be assessed in the treatment and placebo group. Thyroid supplementation will increase the cardiac function and will make the patients extubated early than the patients without supplementation | Until patients extubated after surgery in ICU OR died OR still intubated within 7 days |
| Measure | Description | Time Frame |
|---|---|---|
| Number of patients with low cardiac output syndrome | Identified patients with low cardiac output syndrome in which had clinical signs and symptoms of low cardiac output are found with without the increasing of arterial and venous gap and metabolic acidosis and this condition needs 100% of inotropic support or even more than that from the beginning of inotropic used, the use of new inotropic, mechanical support, or other manoeuvres in order to increase cardiac output (e.g pacemaker) |
| Measure | Description | Time Frame |
|---|---|---|
| Inotropic and vasoactive-inotropic score | The amount of inotropic drugs are calculated and reviewed serially since cross clamp removal until all drugs are stopped | 1, 6, 12, 18, 24, 36, 48, 60 and 72 hours post cross clamp removal |
| Diuresis |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Eva M Marwali, MD, PhD | National Cardiovascular Center Harapan Kita Jakarta | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Pediatric Cardiac ICU National Cardiovascular Center Harapan Kita | Jakarta | DKI Jakarta | 11420 | Indonesia |
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| ID | Term |
|---|---|
| D005067 | Euthyroid Sick Syndromes |
| D006330 | Heart Defects, Congenital |
| ID | Term |
|---|---|
| D013959 | Thyroid Diseases |
| D004700 | Endocrine System Diseases |
| D018376 | Cardiovascular Abnormalities |
| D002318 | Cardiovascular Diseases |
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| ID | Term |
|---|---|
| D014284 | Triiodothyronine |
| ID | Term |
|---|---|
| D013970 | Thyronines |
| D013963 | Thyroid Hormones |
| D006728 | Hormones |
| D006730 | Hormones, Hormone Substitutes, and Hormone Antagonists |
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| Placebo | Drug | Placebo consist of saccharin lactis that has the same appearance as Tetronine |
|
|
| 6 hours, 12 hours, 18 hours, 24 hours, 48 hours post aortic cross clamp removal |
| Drug adverse reaction | Heart rate to evaluate tachycardia, blood pressure for hypertension, heart rate for arrhythmia, body temperature for hyperthermia | Every hourly until 12 hours post cross clamp removal, every 3 hours until 24 hours, every 6 hours until 48 hours, every 12 hours until 72 hours post cross clamp removal, and until the patients discharge from hospital |
Amount of urine output per kg body weight per hour
| From day 1 until day 3 post surgery |
| Fluid balance | Difference between input and output of the fluid per kg body weight per day | From day 1until day 3 post surgery |
| Lactate-pyruvate ratio | Lactate and pyruvate serum was obtained from central venous catheter in internal jugular vein with the distal tip catheter in the right atrium | On induction of anaesthesia, 1 hour, 24 hours post cross clamp removal |
| Ejection Fraction | Ejection Fraction is measured by Echocardiography | Day 1, 2 and 3 post surgery |
| Cardiac Index | Cardiac index is measured by Echocardiography | Day 1, 2 and 3 post surgery |
| Systemic Vascular Resistance Index | Systemic Vascular Resistance Index is measured by Echocardiography | Day 1, 2 and 3 post surgery |
| Pulse Pressure | Difference between systolic and diastolic pressure | Every hourly until 72 hours post surgery |
| Number of patients with sepsis | Amount of patients diagnosis with sepsis based on Surviving Sepsis Campaign | since day 1 post surgery until patients discharge |
| D006331 | Heart Diseases |
| D000013 | Congenital Abnormalities |
| D009358 | Congenital, Hereditary, and Neonatal Diseases and Abnormalities |
| D013974 | Thyroxine |
| D024322 | Amino Acids, Aromatic |
| D000598 | Amino Acids, Cyclic |
| D000596 | Amino Acids |
| D000602 | Amino Acids, Peptides, and Proteins |