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NCT Number: NCT01477151

Randomized Isoflurane and Sevoflurane Comparison in Cardiac Surgery

Anesthesia practice in the 21st century is increasingly outcomes-oriented and evidence-based, but there remain significant gaps in our knowledge, even for commonly-encountered clinical situations. Currently, the two most commonly used drugs used for maintenance of anesthesia in cardiac surgical patients are isoflurane and sevoflurane. There is a belief among many cardiac anesthesiologists that sevoflurane is a better cardiac anesthetic than isoflurane, but there is very little data to support this notion. In fact, very little is known about their comparative effects on important patient outcomes because there has not been a large head-to-head prospective randomized clinical trial. This project will supply the data necessary to critically compare the two anesthetics.

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Key information

Conditions

Coronary Artery Disease Arterial Occlusive Diseases Arteriosclerosis Cardiovascular Diseases Coronary Disease Heart Diseases Heart Valve Diseases Myocardial Ischemia Valvular Heart Disease Vascular Diseases

Age range

18 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Phase 4

Primary location

University Hospital - London Health Sciences Centre

London, Ontario, N6A5A5, Canada

About this study

Current evidence supports the superiority of sevoflurane for myocardial protection during cardiac surgery when compared to total intravenous anesthesia with propofol. However, there is no evidence to suggest that sevoflurane is superior to isoflurane for myocardial protection during cardiac surgery. Sevoflurane may potentially reduce the rate of post-cardiac surgery atrial fibrillation and the time to tracheal extubation compared to isoflurane, but the literature is equivocal on these two important outcomes. Anesthesiologists still frequently use isoflurane for maintenance of cardiac anesthesia, and this is likely because there is substantial uncertainty about whether or not sevoflurane is superior to isoflurane, given the lack of head-to-head RCTs. A large, prospective, pragmatic RCT can ultimately assist clinicians by providing evidence of the non-inferiority (or, possibly the superiority) of one anesthetic compared to the other on important patient outcomes such as ICU length of stay, mortality, renal dysfunction, time to tracheal extubation after cardiac surgery, rates of clinically-important atrial fibrillation, and myocardial damage.

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • Patients must be 18 years or over (There is no upper age limit to enrollment)
  • Eligible procedures are: CABG on-pump or off-pump, single valve repair/replacement, or CABG/single valve combined procedures

Exclusion criteria

  • Cardiac surgeries that are not one of the included cases
  • Planned extubation in the operating room
  • Patients refusing blood products (vis à vis blood sampling)
  • Pregnant patients
  • Malignant hyperthermia or documented/stated allergy to potent volatile anesthetic agents

Treatment and study plan

Volatile anesthetic

Drug

The intervention in this trial is randomization to either maintenance of anesthesia with sevoflurane or maintenance of anesthesia with isoflurane. The designated volatile anesthetic will be given at a strict minimal amount throughout the entire cardiac surgery (including cardiopulmonary bypass). This regimen (administration throughout the entire operation) has proved to have the greatest efficacy. Apart from this intervention, the anesthetic for patients participating in this trial will not be substantially different from normal practice, as the intention is to allow normal practice (with the exception of the choice of volatile anesthetic agent) to maximize the applicability and external validity of the trial. The management of anticoagulation, cardiac surgical techniques, and other aspects of the procedure will be managed in an unaltered fashion.

No IV drug infusions will be permitted until after protamine administration.

Primary outcomes

  1. Composite of: prolonged ICU stay (>= 48 hours) OR death within 30 days of operation

    Time frame: 30 days of operation

Secondary outcomes

  1. Postoperative cardiac troponin T

    Time frame: 6 hours after admission to ICU

    Troponin T sampled at 6 hours after admission to the ICU. The time of sampling will be recorded. The sample will be taken from an indwelling venous or arterial cannula (if one exists) or by venipuncture.

  2. Length of stay in the ICU (criteria)

    Time frame: Participants will be followed for the duration of ICU stay, an expected average of 1 day

    The time from admission in ICU (time 0) until the patient's transfer orders to the floor are enacted.

  3. 30-day all-cause mortality

    Time frame: 30 days after operation

    A participant who has died for any reason before the end of 30th day after the operation. Day 1 is the first calendar day after first being admitted to the ICU.

  4. Duration of tracheal intubation

    Time frame: Participants will be followed for the duration of ICU stay, an expected average of 1 day

    The time from being admitted to the ICU (time 0) until the patient's tracheal tube is removed for the first time.

  5. Inotrope or vasopressor usage in the ICU

    Time frame: Participants will be followed for the duration of ICU stay, an expected average of 1 day

    A participant who is treated at any time after the first hour of their ICU stay with an inotropic or vasopressor by infusion.

  6. Prolonged inotrope or vasopressor usage in the ICU

    Time frame: Participants will be followed for the duration of ICU stay, an expected average of 1 day

    Any patient requiring 12 or more continuous hours of any combination of inotropic or vasopressor agent (including the first hour) in the ICU.

  7. Peak postoperative serum creatinine

    Time frame: Participants will be followed for the duration of hospital stay, an expected average of 1 week

    Peak postoperative creatinine as recorded in the hospital chart.

  8. New-onset dialysis

    Time frame: Participants will be followed for the duration of hospital stay, an expected average of 1 week

    Any patient, not previously on dialysis, requiring postoperative dialysis (hemodialysis or peritoneal dialysis).

  9. Incidence of new-onset atrial fibrillation

    Time frame: Until end of post-operative day 4

    We will capture the proportion of patients who have clinically significant new atrial fibrillation at any time from ICU admission until the end of POD 4. The adjudication of atrial fibrillation will be recorded by the blinded research nurse.

  10. Incidence of intra-aortic balloon pump usage

    Time frame: Participants will be followed for the duration of ICU stay, an expected average of 1 day

    The proportion of patients having an intra-aortic balloon pump inserted (either in the operating room or in the ICU).

  11. Length of stay in the ICU (actual)

    Time frame: Participants will be followed for the duration of ICU stay, an expected average of 1 day

    The time from admission in ICU (time 0) until the patient is discharged from the ICU.

  12. Length of stay in the hospital (actual)

    Time frame: Participants will be followed for the duration of hospital stay, an expected average of 1 week

    The time from admission to the ICU until the patient is discharged home from the hospital.

  13. Readmission to ICU

    Time frame: Participants will be followed for the duration of hospital stay, an expected average of 1 week

    Readmission to the ICU for any reason.

  14. Perioperative stroke

    Time frame: Participants will be followed for the duration of hospital stay, an expected average of 1 week

    A new neurological abnormality persisting > 24 hours with documentation by formal neurological examination and evidence of new brain lesions on a brain imaging study.

  15. 1-year all-cause mortality

    Time frame: One year after operation

    A participant who has died for any reason within the first year after the operation. For example, if the operation takes place on June 20 2011, then mortality up to and including June 19 2012 will be counted.

Sponsors and collaborators

Lead sponsor

London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's

Other

Registry information

Official study title

Randomized Isoflurane and Sevoflurane Comparison in Cardiac Surgery: A Prospective Randomized Clinical Trial.

Acronym: RISCCS

Important dates

Study start
2011
Primary completion
2015
Study completion
2015
First posted
Nov 22, 2011
Registry last updated
Jun 8, 2015

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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