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| ID | Type | Description | Link |
|---|---|---|---|
| 2023-508255-39-00 | EU Trial (CTIS) Number |
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| Name | Class |
|---|---|
| Medical Research Agency, Poland | OTHER_GOV |
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The effect of noradrenaline infusion versus standard blood pressure management on perioperative HYPotension in NOn-caRdiac surgery.
The study aims to determine whether perioperative noradrenaline infusion is superior to standard blood pressure management for the occurrence of perioperative hypotension.
Patients will receive either noradrenaline infusion or standard blood pressure management during and up to 4 hours after surgery. Patients and health care providers will not be blinded to patients' allocation to either arm of the trial. Continuous blood pressure measurements will be secured in all patients who do not have an arterial line already in place for other indications using a non-invasive volume-clamp method. The medical team will not be aware of the continuous blood pressure monitoring and will use solely non-invasive blood pressure measurements at time intervals at least every 5 minutes in the operating room, and at least every 15 minutes in the post-anaesthesia care unit . In each group, patients will receive balanced crystalloids at 4 ml/kg per hour as maintenance fluid during surgery. In mechanical ventilation, a tidal volume of 8 mL/kg predicted body weight will be recommended. Other ventilatory settings, optimisation of volume status, depth of anaesthesia, patient positioning, as well as prompt diagnosis and treatment of reversible causes of hypotension will be prioritised in all patients in adherence with institutional protocols and current standards of practice.
The study aims to determine whether perioperative noradrenaline infusion can reduce exposure to hypotension compared to reactive treatment of hypotension, whether it is more effective in controlling hypotension during the intraoperatively and postoperatively, whether it reduces the risk of postoperative organ dysfunction, and whether it is safe and does not increase the risk of potential complications.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Intervention group | Active Comparator | In the intervention group, a standardized noradrenaline infusion at a concentration of 10 µg/mL will be initiated 15 to 60 seconds before induction of anaesthesia. The infusion will be titrated and maintained during surgery and postoperatively for up to 4 hours, with a minimum duration of 2 hours, until haemodynamic stability is achieved. Haemodynamic stability is defined as stable blood pressure requiring minimal noradrenaline support of 0.01 µg/kg/min or less for at least 1 hour. We will mandate avoidance of mean arterial pressure decreasing below 60 to 70 mm Hg. Once haemodynamic stability is achieved during the postoperative observation period, noradrenaline infusion may be discontinued. Safety criteria for discontinuation include systolic blood pressure above 180 mm Hg, in which case the infusion will be stopped. If systolic blood pressure is between 140 and 170 mm Hg, dose reduction or continuation at a very low noradrenaline infusion of 0.005 µg/kg/min, approximately 1 mL per h |
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| Control group | Active Comparator | Standard blood pressure management reactive to blood pressure values. According to the 2022 ESA/ESC guidelines, patients in the control group will be treated to avoid a mean arterial pressure below 60 to 70 mm Hg. Ephedrine boluses (5 mg per bolus, up to a total intravenous dose of 25 mg) are recommended as first line treatment for hypotension. If hypotension persists, peripheral noradrenaline may be administered. Due to variability in clinical practice regarding the choice and timing of vasopressors and fluid therapy during and after surgery, further protocolization of hypotension management will not be mandated in order to enhance feasibility and generalizability of the trial. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| noradrenaline infusion for management blood pressure | Drug | A single concentration of noradrenaline (10 μg/ml) will be initiated 15-60 seconds prior to the induction of anaesthesia, then titrated and maintained until 4 hours after surgery to meet pre-specified mean arterial pressure (MAP) targets. The drug infusion will be started at a dose of 0.01 μg/kg/min and will be titrated to a maximum of 0.1 μg/kg/min. Anaesthesiologists will be advised to use the lowest possible dose of noradrenaline. Avoidance of MAP decreases of >20% from baseline values or <60-70 mm Hg will be required in both groups. Individual baseline MAP value will be defined as resting blood pressure obtained in at least two measurements at the surgery ward on the day before surgery. Noradrenaline will be administered peripherally in all patients who do not have a central venous catheter in place. |
| Measure | Description | Time Frame |
|---|---|---|
| Perioperative hypotension | Number of episodes of perioperative hypotension defined as any mean arterial pressure (MAP) reading ≤55 mm Hg in the setting of a continuous blood pressure measurement. | During and up to 4 hours after surgery |
| Measure | Description | Time Frame |
|---|---|---|
| Myocardial Injury after Non-cardiac Surgery (MINS) | Number of patients who experience MINS defined as any myocardial infarction and any acutely elevated postoperative cardiac troponin judged as resulting from myocardial ischemia using Roche's fifth generation Elecsys hsTnT, with an established cut-off of 20 ng/L combined with an absolute change of 5 ng/L or more (judged as due to ischemia) | During hospitalization and up to 30 days after surgery |
| Measure | Description | Time Frame |
|---|---|---|
| Lowest MAP throughout the procedure | Number of patients who experience the lowest MAP throughout the procedure, defined as the lowest punctual measurement of mean arterial pressure | During surgery |
| Median mean arterial pressure |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Bożena Seczyńska, PhD | Contact | (+48) 124332847 | bozena.seczynska@uj.edu.pl | |
| Zbigniew Putowski, MD, PhD | Contact | (+48) 126308267 | zbigniew.putowski@uj.edu.pl |
| Name | Affiliation | Role |
|---|---|---|
| Wojciech Szczeklik, MD, PhD | Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College | Study Director |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Uniwersyteckie Centrum Kliniczne im. Prof. Kornela Gibińskiego Śląski Uniwersytet Medyczny | Recruiting | Katowice | 40-752 | Poland |
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| standard blood pressure management | Combination Product | Patients in the control group will receive standard blood pressure management reactive to blood pressure values. In the light of the current ESA/ESC 2022 guidelines, all patients in the control group will be treated to avoid MAP <60-70 mm Hg. Ephedrine boluses (5 mg each, up to 25 mg total intravenous dose) will be recommended as a first-line hypotension treatment. Subsequent treatment will involve administering peripheral noradrenaline. Notwithstanding, there is a variation in clinical practice regarding the choice and timing of vasopressors and fluids to be administered during and after surgery, therefore, hypotension treatment will not be further protocolized to increase the feasibility and generalizability of the trial. |
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| Acute kidney injury fulfilling Kidney Disease Improving Global Outcomes (KDIGO) criteria | Number of patients who experience an acute kidney injury (fulfilling KDIGO criteria) | During hospitalization and up to 30 days after surgery |
| Stroke | Number of patients who experience a stroke is defined as a new focal neurological deficit thought to be vascular in origin with signs or symptoms lasting more than 24 hours or leading to death. Stroke will be sub-classified into hemorrhagic and non-hemorrhagic stroke. | During hospitalization and up to 30 days after surgery |
| Non-fatal cardiac arrest | Number of patients who experience non-fatal cardiac arrest defined as successful resuscitation from either documented or presumed ventricular fibrillation, sustained ventricular tachycardia, asystole, or pulseless electrical activity (PEA) requiring cardiopulmonary resuscitation, pharmacological therapy, or cardiac defibrillation | During hospitalization and up to 30 days after surgery |
| Sepsis | Number of patients who experience sepsis is defined as an increase in SOFA score of 2 or more, with evidence of infection. This outcome includes septic shock defined as sepsis with shock (vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mM [above18 mg/dL] in the absence of hypovolemia). Infection is defined as a pathologic process caused by the invasion of normally sterile tissue or fluid or body cavity by pathogenic or potentially pathogenic organisms. | During hospitalization and up to 30 days after surgery |
| Death | Number of patients who die of any cause | During hospitalization and up to 30 days after surgery |
| Infusion-related reactions | The number of patients who experience infusion-related reactions, defined as disorders such as flushing, rash, fever, rigors, chills, dyspnoea, bronchospasms, cardiac dysfunction, and anaphylaxis. Grades of infusion site extravasation are defined according to the Common Terminology Criteria for Adverse Events. | During the infusion of noradrenaline and up to 30 days after drug administration, with assessment occurring postoperatively. |
| Days alive and out of hospital | Number of days when a patient is alive and out of hospital | 30 days after surgery |
| Clinically important atrial fibrillation | Number of patients who experience clinically important atrial fibrillation, defined as new-onset atrial fibrillation or atrial flutter of any duration on an ECG or rhythm strip, which results in angina, congestive heart failure, symptomatic hypotension, or requires treatment with a rate-controlling drug, antiarrhythmic drug, or electrical cardioversion | During hospitalization and up to 30 days after surgery |
| Major bleeding | Number of patients who experience an International Society on Thrombosis and Haemostasis (ISTH) major bleeding | During hospitalization and up to 30 days after surgery |
| Peripheral ischemia | Number of patients who experience peripheral ischemia defined as the fingertip necrosis of upper and lower limbs | During hospitalization and up to 30 days after surgery |
| During and up to 4 hours after surgery |
| Median heart rate | During and up to 4 hours after surgery |
| Acute Myocardial Infarction | Number of patients who experience acute myocardial injury according to the Fourth Universal Definition of Myocardial Infarction as a detection of an elevated cTn value above the 99th percentile URL with a rise and/or fall of cTn values. | During hospitalization and up to 30 days after surgery |
| Peak troponin concentration | Peak troponin concentration | The first three days after surgery |
| Area under the curve troponin | Area under the curve troponin is defined as total cTn release measured as area under the Troponin-Time curve | The first three days after surgery |
| Bradycardia | Number of patients who experience bradycardia, defined as a heart rate less than 40 beats per minute | During surgery, up to 4 hours after surgery, and up to 30 days after surgery. |
| Acute congestive heart failure | Number of patients who experience acute congestive heart failure defined as an episode characterized by at least one of the following clinical signs (i.e. any of the following signs: elevated jugular venous pressure, respiratory rales/crackles, crepitations, or presence of S3) and at least one of the following: (I) Radiographic findings (i.e. vascular redistribution, interstitial pulmonary edema, or frank alveolar pulmonary edema) OR (II) Heart failure treatment implemented with diuretics with documented clinical improvement | During hospitalization and up to 30 days after surgery |
| Acute Kidney Injury stage 2-3 | Number of patients who experience acute kidney injury stage 2-3 according to KDIGO criteria | 30 days after surgery |
| Pneumonia | Number of patients who experience pneumonia, defined according to the US Centers for Disease Control criteria | During hospitalization and up to 30 days after surgery |
| Postoperative pulmonary complications | Number of patients who experience postoperative pulmonary complications which are a composite outcome comprised of the following outcomes: 1. Atelectasis detected on computed tomography or chest radiograph 2. Pneumonia using US Centers for Disease Control criteria 3. Acute respiratory distress syndrome (according to Berlin definition) 4. Pulmonary aspiration (clear clinical history AND radiological evidence) | During hospitalization and up to 30 days after surgery |
| Surgical site infection | Number of patients who experience surgical site infection defined according to the Centers for Disease Control and Prevention (CDC) criteria | During hospitalization and up to 30 days after surgery |
| Postoperative delirium | Number of patients who experience delirium (based on The Nursing Delirium Screening Scale - NuDESC). A total score of 2 or higher on the scale indicates a positive result for the diagnosis of delirium. | Assessment on postoperative days 1, 2, 3 |
| Discharge destination | Number of patients discharged from the hospital to home/long-term care facility/other | 30 days after surgery |
| Cognitive decline | Number of patients who experience cognitive decline (defined as a decline of at least 2 points on the Montreal Cognitive Assessment, MoCA, performed via telephone) compared to the assessment conducted after consent and before randomization | 30 days after surgery |
| Days alive and outside the intensive care unit | Number of days when a patient is alive and outside the intensive care unit | 30 days after surgery |
| Health-related quality of life | Health-related quality of life will be evaluated (based on the EuroQol 5 Dimension, five-level version [EQ-5D]), compared to the assessment made after consent and before randomization. | 30 days after surgery |
| Lowest MAP during the 4 hours postoperative period | The lowest recorded mean arterial pressure during postoperative monitoring lasting at least 2 hours and up to 4 hours after surgery. | up to 4 hours after surgery |
| Perioperative myocardial infarction/injury | Number of Participants with Perioperative myocardial infarction/injury as defined by the 2022 European Society of Cardiology (ESC) Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery: an absolute increase in hs-cTn concentration of more than the 99th percentile URL after surgery compared to the pre-operative level. In the absence of a preoperative hs-cTn T/I concentration, a hs-cTn more than five-times the 99th percentile URL or an absolute increase or decrease more than the 99th percentile URL | up to 72 hours (3 days) postoperatively |
| 5 Wojskowy Szpital Kliniczny z Polikliniką Samodzielny Publiczny Zakład Opieki Zdrowotnej w Krakowie | Recruiting | Krakow | 30-901 | Poland |
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| Wojewódzki Szpital Specjalistyczny w Olsztynie | Active, not recruiting | Olsztyn | 10-561 | Poland |
| Uniwersytecki Szpital Kliniczny w Opolu | Recruiting | Opole | 45-401 | Poland |
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| Samodzielny Publiczny Szpital Kliniczny Nr 1 im. Prof. Stanisława Szyszko Śląskiego Uniwersytetu Medycznego w Katowicach | Recruiting | Zabrze | 41-800 | Poland |
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| ID | Term |
|---|---|
| D007022 | Hypotension |
| ID | Term |
|---|---|
| D014652 | Vascular Diseases |
| D002318 | Cardiovascular Diseases |
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