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Evaluation of the Effect of Dexmedetomidine on Phenylephrine Response During Refractory Septic Shock (Adress-Pilot)

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ClinicalTrials.gov Identifier: NCT03953677
Recruitment Status : Not yet recruiting
First Posted : May 16, 2019
Last Update Posted : August 28, 2019
Sponsor:
Information provided by (Responsible Party):
Centre Hospitalier Universitaire Dijon

Brief Summary:

Septic shock is common in patients admitted to intensive care and hospital mortality occurs in close to 50% of these patients. In half of the cases, death occurs within the first 72 hours in a context of multiple organ failure that does not respond to conventional therapies, particularly circulatory therapies, despite increasing doses of catecholamines. Vasopressor resistance in septic patients defines refractory septic shock. In one study (Conrad et al. 2015), the increase in blood pressure observed with an infusion of increasing doses of phenylephrine (dose-response curve) made it possible to quickly and clearly identify patients resistant to vasopressors at a high risk of death by refractory shock (ROC AUC 0.92). This resistance is due in particular to a downregulation of α1 adrenergic receptors, linked to sympathetic hyper activation associated with septic shock. To date, there is no validated therapy in this situation. However, experimental data have shown that the administration of α2 agonists, usually used for their sedative (dexmedetomidine) or anti-hypertensive (clonidine) effect, normalizes sympathetic activity towards basal values. In animals, α2 agonists restore the sensitivity of alpha1 adrenergic receptors, resulting in improved vasopressor sensitivity and survival. In humans, a beneficial effect on mortality was suggested in the first trial testing dexmedetomidine in septic patients in 2017. This effect was observed especially in the most severe patients, suggesting a restoration of sensitivity to vasopressors.

The hypothesis is that the administration of dexmedetomidine in patients in refractory septic shock may improve response to phenylephrine and decrease resistance to vasopressors. This pilot study could lay the foundation for a randomized controlled trial.


Condition or disease Intervention/treatment Phase
Septic Shock Vasopressor Resistance Drug: Dexmedetomidine 100 Mcg/mL Intravenous Solution Drug: 5% glucose Infusion solution Phase 3

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 36 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary Purpose: Treatment
Official Title: A Randomized Controlled Pilot Study Evaluating the Effect of Dexmedetomidine on Phenylephrine Response During Refractory Septic Shock
Estimated Study Start Date : October 2019
Estimated Primary Completion Date : April 2021
Estimated Study Completion Date : July 2021

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Shock

Arm Intervention/treatment
Experimental: Dexmedetomidine Drug: Dexmedetomidine 100 Mcg/mL Intravenous Solution
Continuous infusion of dexmedetomidine at 0.7 µg/kg/h for 2 hours and then 1 µg/kg/h at fixed dose

Placebo Comparator: Placebo Drug: 5% glucose Infusion solution
Continuous infusion of placebo (5% glucose) at 0.7 µg/kg/h for 2 hours and then 1 µg/kg/h at fixed dose




Primary Outcome Measures :
  1. Relative change in mean blood pressure, expressed as a percentage [ Time Frame: 6 hours after the end of the initial test ]
    Relative variation in mean blood pressure between the basal value at the beginning of the test and the value reached at the dose of 6 µg/kg/min (%PAM0 = PAMd/PAM0 x100)



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

Inclusion Criteria:

  • Age ≥ 18 years old
  • Septic shock, defined by the "Sepsis-3" criteria

    • proven or suspected infection, with modification of the SOFA score ≥ 2 points,
    • with persistent hypotension requiring vasopressors to maintain MAP > 65 mmHg
    • and a serum lactate level > 2 mmol/L despite adequate vascular filling
  • Adequate vascular filling: ≥ 30ml/kg, absence of preload-dependency criteria (respiratory variability of the inferior vena cava, passive leg lift, pulsed pressure variation)
  • Catecholamine resistance, defined by the need for a dose of norepinephrine ≥ 1 µg/kg/min achieved within 12 hours of admission or ≥ 2µg/kg/min achieved between 12 and 24 hours after admission
  • Mechanical ventilation
  • Under sedation by midazolam or propofol
  • Informed consent obtained from a relative for patient included in an emergency
  • Patient affiliated to the national health insurance system

Exclusion Criteria:

  • Cardiac arrest before inclusion and occurring before septic shock criteria are met
  • Cardiac index < 2.2 l/min/m² after volume correction, or left ventricular ejection fraction < 40% on echocardiography
  • Bradycardia < 55 bpm (apart from treatment with β-blocker) or 2nd or 3rd degree BAV not equipped
  • Proven or suspected decompensation of coronary heart disease
  • Acute cerebrovascular condition
  • Severe hepatic insufficiency with TP and factor V <50%
  • Patient on adrenaline or vasopressors
  • Patient on non-selective MAOI iproniazid within 15 days of inclusion
  • Patient for whom a decision has been made to limit the use of therapies
  • Hypersensitivity to dexmedetomidine or phenylephrine
  • Patient on dexmedetomidine before inclusion
  • Person subject to a legal protection measure (curatorship, guardianship)
  • Person subject to limited judicial protection
  • Pregnant, parturient or breastfeeding woman
  • Patient with suspected or confirmed mesenteric ischemia

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03953677


Contacts
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Contact: Auguste DARGENT 03.80.29.37.51 ext +33 auguste.dargent@chu-dijon.fr

Locations
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France
Chu Dijon Bourgogne Not yet recruiting
Dijon, France, 21000
Contact: Auguste DARGENT    03.80.29.37.51 ext +33    auguste.dargent@chu-dijon.fr   
Sponsors and Collaborators
Centre Hospitalier Universitaire Dijon

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Responsible Party: Centre Hospitalier Universitaire Dijon
ClinicalTrials.gov Identifier: NCT03953677     History of Changes
Other Study ID Numbers: DARGENT APJ 2018
First Posted: May 16, 2019    Key Record Dates
Last Update Posted: August 28, 2019
Last Verified: May 2019

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Additional relevant MeSH terms:
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Shock, Septic
Shock
Pathologic Processes
Sepsis
Infection
Systemic Inflammatory Response Syndrome
Inflammation
Phenylephrine
Oxymetazoline
Dexmedetomidine
Pharmaceutical Solutions
Hypnotics and Sedatives
Central Nervous System Depressants
Physiological Effects of Drugs
Analgesics, Non-Narcotic
Analgesics
Sensory System Agents
Peripheral Nervous System Agents
Adrenergic alpha-2 Receptor Agonists
Adrenergic alpha-Agonists
Adrenergic Agonists
Adrenergic Agents
Neurotransmitter Agents
Molecular Mechanisms of Pharmacological Action
Cardiotonic Agents
Mydriatics
Autonomic Agents
Sympathomimetics
Vasoconstrictor Agents
Nasal Decongestants