Clinical Trials Logo

Clinical Trial Summary

The cardiogenic shock is characterized by an alteration of organs function following a decrease in cardiac output linked to an impairment of cardiac performance. The prognosis remains poor with mortality between 40 and 50%. Nowadays, Extracorporeal Life Support (ECLS or VA-ECMO) is the referent therapy to restore blood flow in the body when medical treatment is not sufficient. Despite a good blood flow provided by the ECLS, many patients develop a severe hypotension (so called vasoplegia) due to a loss of vascular resistance mainly explained by the inflammatory response to shock and extracorporeal circulation. The treatment of this reaction includes vasopressors (Norepinephrine in usual care) and serum surrogate perfusion to achieve a mean arterial pressure (MAP) above 65 mmHg.

The purpose of this study is to describe the patients with vasoplegia among a retrospective cohort of patients treated with an ECLS in our university center, over the 4 last years, to determine major complication rate (including death, kidney failure and arrythmias) and their outcome. This study will provide consistent data useful for further trials about targets of pressure and treatments to increase blood pressure during ECLS.


Clinical Trial Description

Cardiogenic shock is characterized by global tissue hypoperfusion following a decrease in cardiac output by impairing myocardial performance in the absence of hypovolemia. This life-threatening hypoperfusion quickly leads to multiple organs dysfunction with a high risk of cardiac arrest. The main cause is ischemic. The prognosis remains poor with mortality between 40 and 50% and depends on the speed of care by a specialized team. Early etiologic treatment is essential, but initial symptomatic management is based on catecholamines, mainly norepinephrine and dobutamine. The intra-aortic balloon pump showed no improvement in survival in large randomized studies. Refractory cardiogenic shock is defined by the inefficiency or intolerance of catecholamines and the indication of temporary circulatory support should be considered as soon as possible in the absence of contraindications (comorbidities, advanced age, therapeutic limitation). The veno-arterial extracorporeal membrane oxygenation (VA-ECMO or ECLS) is the preferred circulatory assistance in this indication because it provides an overall circulatory support up to 100% of the theoretical cardiac output, with oxygenation, and is quickly implanted peripherally (surgical or percutaneous cannulation of the femoral vein and the femoral artery). However, this extracorporeal circulation also has disadvantages by opposing a major afterload to the failing left ventricle and reducing or even abolishing the pulmonary circulation and blood flow in the heart chambers. In addition, the interaction with the artificial surfaces and the oxygenation membrane of the extracorporeal circuit contributes to the inflammatory response already initiated as a result of low cardiac output, tissue hypoperfusion, mesenteric ischemia and possibly myocardial infarction in case of acute coronary syndrome. This systemic inflammatory response syndrome (SIRS) is similar to sepsis and its main clinical presentation is a vascular dysfunction resulting in vasoplegia and capillary leak syndrome responsible for relative hypovolemia and interstitial inflation.

Since the flow provided by the centrifugal pump is continuous, the blood pressure under VA-ECMO presents low or no pulsatile waves and is better represented by the mean arterial pressure (MAP). The ideal targets of MAP under VA-ECMO are controversial but it is widely accepted that the MAP should not be less than 65mmHg as recommended in septic shock to maintain an acceptable perfusion pressure and should not exceed 95mmHg to limit afterload. Between these limits, the MAP must be individualized according to each situation (hypertensive patient for example). In France, Norepinephrine is the first-line drug to achieve this goal of MAP after correction of volemia, without dose limitation in the absence of currently validated alternative, while resistance mechanisms can be activated, and its efficiency may be limited in case of acidosis. Potential side effects are the occurrence of atrial or ventricular arrhythmias, tachycardia, pro-inflammatory cytokine release, immunosuppression, renal dysfunction.

Management of MAP and vasopressors under VA-ECMO is poorly described in the literature (5), although Norepinephrine is widely used in routine practice. In particular, the investigators do not know the frequency of use and Norepinephrine doses during ECMO-VA, as well as their prognostic involvement. Vasoplegia during VA-ECMO is defined by a Norepinephrine dose greater than 0.1µg/kg/min after a 500ml fluid challenge despite overall blood flow (ECMO + native heart) greater than 2l/min/m2 or allowing to achieve 65% of ScvO2.

This cohort study aims to describe the vasoplegia observed during VA-ECMO, the Norepinephrine treatment characteristics, complications and outcome. The primary end-point is the incidence of a composite criteria of major complications including death, acute kidney injury and arrythmias. ;


Study Design


Related Conditions & MeSH terms


NCT number NCT03968926
Study type Observational
Source University Hospital, Montpellier
Contact Philippe Gaudard, MD
Phone +33665849543
Email p-gaudard@chu-montpellier.fr
Status Recruiting
Phase
Start date June 30, 2019
Completion date December 30, 2020

See also
  Status Clinical Trial Phase
Completed NCT04062994 - A Clinical Decision Support Trial to Reduce Intraoperative Hypotension
Active, not recruiting NCT02016599 - Effects of Transitional Circulation in ELBW Infants
Recruiting NCT05836610 - Hydrocortisone Therapy Optimization During Hypothermia Treatment in Asphyxiated Neonates Phase 4
Completed NCT02907931 - Carotid Doppler Ultrasound for the Measurement of Intravascular Volume Status N/A
Completed NCT03215797 - Phenylephrine or Norepinephrine for a Better Hemodynamic Stability Phase 3
Suspended NCT02315937 - Hemodynamic Assessment During Spinal Anesthesia Using Transthoracic Echocardiography' N/A
Recruiting NCT02532270 - Detecting Hypotension By Continuous Non-invasive Arterial Pressure Monitoring N/A
Completed NCT02802683 - Hemodynamic Impact of Hyperbaric Versus Isobaric for Spinal Anesthesia During Cesarean Delivery Phase 4
Completed NCT02437799 - Dicrotic Notch and Hypotension at Caesarean Under Spinal Anaesthesia N/A
Completed NCT01930227 - Transcutaneous Electrical Acupoint Stimulation(TEAS) for Hypotension After Spinal Anesthesia in Parturients N/A
Not yet recruiting NCT01941472 - Transcutaneous pO2, Transcutaneous pCO2 and Central Venous pO2 Variations to Predict Fluid Responsiveness N/A
Completed NCT02146898 - The Severity Of Hypotension Comparing Three Positions During Spinal Anesthesia For Cesarean Delivery N/A
Recruiting NCT01434251 - Treatment of Hypotension of Prematurity (TOHOP) N/A
Completed NCT01592669 - Passive Leg Raising Attenuates and Delays Tourniquet Deflation-induced Hypotension and Tachycardia N/A
Withdrawn NCT01183741 - Accuracy of Non-Invasive Blood Pressure Measurement in Adults Phase 3
Completed NCT00991627 - Different Approaches to Maternal Hypotension During Cesarean Section Phase 4
Withdrawn NCT00750516 - Lactic Acid Levels In Hypotensive Patients Without(Standard) and With Tourniquet
Completed NCT00115726 - Trial Assessing the Effect of Preoperative Furosemide on Intraoperative Blood Pressure Phase 4
Recruiting NCT05513066 - Management Arterial Hypotension During Planned Caesarean Section, Intravenous Ephedrine/Phenylephrine Mixture Versus Intravenous Baby Noradrenaline
Completed NCT04089644 - Manual vs Closed-loop Control of Mean Arterial Pressure N/A