Thiamine v placebo to improve oxygen consumption after in-hospital cardiac arrest

硫胺素与安慰剂对比改善院内心脏骤停后的耗氧量

• 批准号: 9766409
• 负责人: Katherine M Berg
• 金额: $ 19.09万
• 依托单位: BETH ISRAEL DEACONESS MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-09-01 至 2021-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9766409
• 关键词: Acidosis; Anaerobic Bacteria; Antihypertensive Agents; Award; Back; Blinded; Blood Circulation; Cardiac; Cardiac Surgery procedures; Cause of Death; Cell Respiration; Cells; Cessation of life; Characteristics; Citric Acid Cycle; Critical Illness; Data; Death Rate; Defect; Development Plans; Disease; Dose; Enrollment; Enzymes; Event; Failure; Fever; Functional disorder; Heart Arrest; Hospitals; Hour; Hypoxemia; Impairment; Intervention; Lactate Dehydrogenase; Lactic Acidosis; Lead; Literature; Measurement; Measures; Mentorship; Metabolic; Metabolism; Mitochondria; Monitor; Morbidity - disease rate; Nervous System Trauma; Neurological outcome; Outcome; Oxygen; Oxygen Consumption; Patients; Phase; Physiologic pulse; Physiological; Placebos; Process; Production; Pyruvate; Randomized; Randomized Controlled Trials; Refractory; Research; Research Personnel; Respiratory Failure; Resuscitation; Sepsis; Septic Shock; Severity of illness; Shock; Stress; Syndrome; Tachycardia; Temperature; Testing; Thiamine; Thiamine Deficiency; Time; Tissues; Translational Research; United States; Vasoconstrictor Agents; career development; experience; heart preservation; improved; improved outcome; indexing; metabolic rate; mitochondrial dysfunction; mortality; mouse model; placebo controlled study; primary outcome; public health relevance; pyruvate dehydrogenase; secondary outcome; sedative; skills; survival outcome

 DESCRIPTION (provided by applicant): Over 200,000 people suffer an in-hospital cardiac arrest (IHCA) each year in the United States, and over 80% of those will die. In spite of this extremely high mortality, relatively few trials have been done to investigate treatments to improve outcomes after IHCA. In patients who achieve return of spontaneous circulation (ROSC), the most common cause of death is shock and multi- organ failure. The post-arrest syndrome has been likened to sepsis/septic shock, and both conditions appear to be characterized by impaired oxygen extraction in many patients. This may contribute to increased lactate, failure to clear lactate, and decreased oxygen consumption (VO2), all of which are associated with higher mortality in both sepsis and post-cardiac arrest. We have also found that pyruvate dehydrogenase (PDH), an enzyme required for the Krebs Cycle, is low in sepsis and after cardiac arrest, and that lower levels are associated with higher mortality in sepsis. All of these indicators suggest a dysfunction in aerobic metabolism, and an intervention that could rectify this defect could lead to lower lactate values, increased VO2 and potentially better outcomes. Thiamine, a co-factor of PDH, is also required for aerobic metabolism. We have found that thiamine deficiency is common in septic shock and after cardiac arrest, and that thiamine levels are inversely associated with lactate levels in septic shock and other forms of critical illness. We have also found that thiamine administration lowers lactate and improves survival in thiamine deficient septic shock patients, is associated with a rise in VO2 in criticall ill patients with preserved cardiac index (regardless of thiamine level), and appears to increase PDH activity after major cardiac surgery. We therefore hypothesize that thiamine will increase VO2, increase PDH activity and decrease lactate after IHCA. We propose a phase II randomized, blinded, placebo-controlled trial in 60 patients who obtain sustained ROSC after in-hospital cardiac arrest and have preserved cardiac index to test this hypothesis. All enrolled patients will be randomized to either thiamine 200mg or placebo every 12 hours for 24 hours. We will record VO2 and cardiac index data continuously for 24 hours, and will check PDH quantity and activity and lactate at 0, 12 and 24 hours. The primary outcome will be the change in VO2, and the secondary outcomes will be change in PDH activity and lactate. We anticipate that VO2 and PDH activity will rise while lactate will decrease in patients who receive thiamine as compared to placebo. Prior research on VO2 after cardiac arrest is extremely limited, and as such we believe our data will be a significant contribution to the literature on cardiac arrest and the post-arrest syndrome, even if our study results are not positive.

 描述(申请人提供)：在美国，每年有超过20万人在医院内心脏骤停(IHCA)，其中超过80%的人将死亡。尽管死亡率极高，但对IHCA后改善结果的治疗进行的试验相对较少。在实现自主循环恢复(ROSC)的患者中，最常见的死亡原因是休克和多器官衰竭。停搏后综合征被比作败血症/感染性休克，在许多患者中，这两种情况似乎都以氧摄取受损为特征。这可能会导致乳酸盐增加、乳酸清除失败和氧耗(VO2)减少，所有这些都与败血症和心脏骤停后较高的死亡率有关。我们还发现，丙酮酸脱氢酶(PDH)是Krebs循环所需的一种酶，在脓毒症和心脏骤停后，丙酮酸脱氢酶(PDH)水平较低，并且较低的水平与脓毒症的较高死亡率有关。所有这些指标都表明有氧代谢功能障碍，可以纠正这一缺陷的干预措施可能会导致乳酸值降低，VO2增加，并有可能获得更好的结果。硫胺素是PDH的辅助因子，也是有氧代谢所必需的。我们发现，在感染性休克和心脏骤停后，硫胺素缺乏是常见的，并且在感染性休克和其他形式的危重疾病中，硫胺素水平与乳酸水平呈负相关。我们还发现，在硫胺素缺乏的感染性休克患者中，给予硫胺素可以降低乳酸并改善存活率，与心脏指数保持不变的危重患者的VO2增加有关(与硫胺素水平无关)，并似乎在心脏大手术后增加PDH活性。因此，我们推测硫胺素会增加IHCA后的VO2，增加PDH活性，降低乳酸。我们提出了一项II期随机、双盲、安慰剂对照试验，在60名住院心脏骤停后获得持续ROSC并保存了心脏指数的患者中进行试验，以验证这一假设。所有入选的患者将被随机分为硫胺素200毫克或安慰剂，每12小时服用一次，持续24小时。连续24小时记录VO2和心脏指数数据，并在0、12、24小时检测PDH含量、活性和乳酸。主要结果将是VO2的变化，次要结果将是PDH活性和乳酸的变化。我们预计，与安慰剂相比，接受硫胺素治疗的患者的VO2和PDH活性将上升，而乳酸将下降。先前关于心脏骤停后VO2的研究极其有限，因此我们相信我们的数据将对心脏骤停和心脏骤停的文献做出重大贡献。 逮捕后综合症，即使我们的研究结果不是积极的。