Inhaled Nitric Oxide for Cardiac Arrest in Pediatrics and Adults (iNOCAPA)
This study is a multi-center, double blind, randomized controlled trial of inhaled nitric oxide (iNO) in children and adults with cardiac arrest (CA). The purpose of this pilot study is to test the feasibility of rapidly randomizing patients to iNO or sham treatment during cardiopulmonary resuscitation (CPR) or shortly after return of circulation (ROC) and evaluate blood biomarkers associated with iNO compared to sham. Return of circulation may refer to return of spontaneous circulation (ROSC) or ROC through extracorporeal cardiopulmonary resuscitation (E-CPR).
Arms and Interventions
|Sham Comparator: Participants with Sham (no nitric oxide)
The mechanical ventilator circuit of the study participants are attached to the inhaled nitric oxide delivery device but nitric oxide is not delivered.
In patients randomized to sham, the iNO delivery device will be connected to the ventilator circuit or manual ventilation bag but flow of iNO will not be turned on. For the purposes of patient safety and to maintain blinding, the respiratory therapists (RTs) will continue checks of gas flow, flow adjustments and change iNO gas tanks at rates like routine clinical procedures on patients treated with iNO or sham.
|Experimental: Participants with Nitric Oxide
The mechanical ventilator circuit of the study participants are attached to the inhaled nitric oxide delivery device and nitric oxide is delivered.
Drug: inhaled nitric oxide (iNO)
In patients randomized to the this arm, iNO will be delivered into the ventilator circuit through the endotracheal tube or tracheostomy. The dose will be 80 ppm during chest compressions and reduced to 20 ppm immediately following ROC. If the patient is enrolled following ROC, the dose will be 20 ppm. Dose modifications will occur if there is toxicity or if there is a clinical concern. The iNO or sham will be continued for 72 hours or until extubation.
Primary Outcome Measures
- Drug Procedural Feasibility [We will monitor screening numbers, rates of enrolment of eligible patients and delivery of study intervention according to CONSORT criteria over the 2 year timeframe of study enrolment.]
Number of successful initiations of iNO or sham among the 40 patients enrolled in the study. We will monitor and improve our rates of enrolment and study intervention by examining and improving upon factors related to protocol compliance.
- Drug Procedural Feasibility [We will monitor compliance to the study intervention during the 72 hours of drug/sham delivery and 12 hours of weaning and stopping the study intervention on each enrolled patient over the 2 years of study enrolment.]
Number of successful continuations of iNO or sham for 72 hours followed by weaning and stopping the study intervention over the next 12 hours. Using real time monitoring of the study intervention we will optimize compliance to the full duration of the study intervention and improve upon any deviations to the study intervention over the full 72 + 12 hours of the study protocol.
Secondary Outcome Measures
- Monitor recruitment rate [For study duration, approximately 2 years.]
Recruitment rate is the rate of enrolment/randomization/consent divided by the number of eligible patients which meet all inclusion criteria and have no exclusion criteria.
- Monitor time to randomization of eligible patients [At study enrollment during the 2 years of study recruitment.]
Timing of randomization. The time of randomization following onset of cardiac arrest will be recorded. We will attempt to speed up this time using simulations with study and clinical personnel and by debriefing each enrolled patient with the teams involved. We will attempt to enrol some patients who have a cardiac arrest in the ICU during chest compressions and for those patients enrolled following return of circulation, the timeframe is a maximum of 5 hours.
- Monitor masking and unmasking events [During the 2 year study duration and data analysis.]
Number of unblinding instances. The study apparatus (inhaled nitric oxide gas delivery device) has a secure cover that only the Respiratory Therapists are trained to open. The RTs will record any unblinding events which may include breaking/cutting of the cover ties and opening of the apparatus cover by clinical personnel other than RTs. The RTs will record and sign 'unblinding yes/no' into their masked RT study case report form on each RT clinical shift and study Research Coordinators will enter this data into the study electronic database. We will monitor unblinding events in real time and attempt to prevent these from happening.
- Study follow-up rates [For study follow-up, approximately 2.5 years.]
We will measure outcomes at 1 and 6 months following cardiac arrest as outlined in more detail below. Number of completed study outcomes at 6 months following cardiac arrest will be followed in real time and we will attempt to maximize follow-up rates.
Other Outcome Measures
- Return of spontaneous circulation (ROSC) [Duration of study enrollment, approximately 2 years.]
Rate of ROSC, for participants in whom the iNO or sham procedure is initiated during chest compressions and cardiopulmonary resuscitation.
- Survival at hospital discharge [For duration of study follow-up, approximately 2 years and 6 months.]
Survival to hospital discharge, 1 month, and 6 months following cardiac arrest.
- Cerebral performance category score [For duration of study follow-up, approximately 2 years and 6 months.]
Cerebral Performance Category (CPC) or Pediatric Cerebral Performance Category (PCPC) scores, for adults and children respectively, at 1 month, and 6 months following cardiac arrest. CPC scores range from 1 to 5 with 1 indicating good outcome, 4 indicating persistent vegetative state and 5 indicating death. PCPC scores range from 1 to 6, with 1 indicating good cerebral performance, 5 indicating persistent vegetative state and 6 indicating death.
- Quality of Life Score [For duration of study follow-up, approximately 2 years and 6 months.]
Pediatric Quality of Life (PedsQL) scores (includes 2 adult versions) at 1 month, and 6 months following cardiac arrest. Results are reverse scored and transformed into a scale with a range of 0 to 100, with higher scores indicate better health related quality of life.
- Quality of life after brain injury [For duration of study follow-up, approximately 2 years and 6 months.]
Quality Of Life after Brain Injury-Overall Scale (QOLIBRI-OS, for adults only) at 1 month, and 6 months following cardiac arrest. QOLIBRI scores are reported on a 0 to 100 scale, with 0 indicating worst possible quality of life and 100 indicating best possible quality of life.
- Blood protein biomarkers [Bloods sampled and banked for up to 7 days post-cardiac arrest. Biomarker measurements will be done after we have recruited 40 patients into the study. i.e. at approximately 2 years after the start of study enrolment.]
Blood will be sampled, and the serum separated and divided into aliquots and banked at 4 time points following enrolment. These time points are within 4 hours following enrolment and with AM clinical blood sampling on Day 2, 4 and 7. Day 1 is defined as the 24 hour period from 00:01 to 24:00 hours during which the patient was enrolled. At the end of the study, a panel of brain specific and inflammatory proteins will be measured in serum samples and their concentrations compared between intervention groups. We will also perform shotgun proteomics using untargeted mass spectrometry and compare blood peptide/protein concentrations from Day 2 samples between the 2 intervention groups. Promising peptides/proteins that may indicate response to iNO will then be measured, using targeted mass spectrometry in serum samples from all 4 time points to determine the time course of these peptides/proteins.
To be eligible to participate in this study, an individual must meet all the following criteria:
Aged 1 day* to 80 years on the day the study intervention is started
In-hospital or out-of-hospital CA with CPR > 5 minutes
It is possible to randomize and start the iNO or sham during CPR or within 5 hours of ROC**
Mechanically ventilated in a study site ICU
Note: *Age 1 day is defined as 24 hours and a minimum corrected gestational age ≥ 38 weeks.
Note: **ROC refers to either ROSC or ROC via extracorporeal cardiopulmonary resuscitation (E-CPR).
An individual who meets any of the following criteria will be excluded from participation in this study:
Unwitnessed cardiac arrest
Cardiac arrest due to birth asphyxia
Pre-arrest poor neurologic function*
Already receiving iNO at the time of CA
Any condition or diagnosis, in the opinion of the PI, Co-Investigators, or MRPs, in which iNO would have adverse effects on physiology or where the cardiac anatomy and physiology has not yet been adequately assessed
Any condition or diagnosis, in the opinion of the PI, Co-Investigators, or MRPs, in which iNO would be indicated as therapy post-arrest
CPR duration > 45 minutes**
Terminal illness ʈ
Note: * Poor neurologic function is defined as CPC ≥ 4 or PCPC ≥ 4.
Note: **CPR duration is defined as total cumulative duration of CPR (i.e., if a patient has multiple arrests with CPR, the duration of these will be added); patients who undergo E-CPR will not be excluded, to maximize recruitment for this feasibility trial.
Note: ***B-HCG screening is not required for enrollment in women of reproductive age, but testing will occur as soon as possible (within 6 hours of enrollment).
Patients who are cannulated to ECMO for cardiorespiratory support will NOT be excluded a priori.
ʈ The MRP knew that the patient was dying pre-arrest
Contacts and Locations
|St. Michael's Hospital
|Toronto General Hospital
|Toronto Western Hospital
|The Hospital for Sick Children
Sponsors and Collaborators
- The Hospital for Sick Children
- Heart and Stroke Foundation of Canada
Study Documents (Full-Text)None provided.