Volatile Anesthetics for COVID-19

(SAVE-ICU Trial)

Not currently recruiting at 15 trial locations

Overseen By Iman Hussain

Age: 18+

Sex: Any

Trial Phase: Phase 3

Sponsor: Sunnybrook Health Sciences Centre

Must be taking: Intravenous sedatives

Must not be taking: Inhaled prostacyclin

Disqualifiers: Severe brain injury, Neuromuscular disorder, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Pivotal Trial (Near Approval) This treatment is in the last trial phase before FDA approval

Prior Safety Data This treatment has passed at least one previous human trial

Compensation: Varies

Number of Visits: Unknown

Duration: 30 days

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial explores new methods to keep patients comfortable on breathing machines when traditional sedatives are scarce. Researchers test inhaled gases, commonly used in surgeries, to determine if they aid faster recovery from lung failure due to COVID-19 or other conditions. The focus is on whether these gases, specifically Isoflurane and Sevoflurane inhalant products, can reduce lung swelling, improve oxygen levels, and shorten time on breathing machines. Suitable candidates for this trial are those on a ventilator due to severe lung problems who have received IV sedation for less than 72 hours. As a Phase 3 trial, this study represents the final step before FDA approval, offering patients a chance to contribute to a potentially groundbreaking treatment.

Will I have to stop taking my current medications?

The trial does not specify if you need to stop taking your current medications. However, it mentions that patients already receiving certain intravenous sedatives are eligible, so you might be able to continue some medications.

Is there any evidence suggesting that this trial's treatments are likely to be safe?

Research has shown that inhaled anesthetics like isoflurane and sevoflurane are generally well-tolerated. Isoflurane has been used in many COVID-19 patients, reducing the need for other sedative drugs, which suggests its safety and effectiveness for sedation. The FDA has approved it for use in surgeries, further supporting its safety.

Sevoflurane has also been studied in COVID-19 patients. Some research indicates it might protect organs during severe inflammation. It has been tested in intensive care units for up to 12 days, suggesting its safety for extended use.

Both gases are used daily in operating rooms and have a strong safety record. Although this study is new, existing evidence is promising regarding their safety for patients needing sedation on breathing machines. ^{1 2 3 4 5}

Why are researchers excited about this trial's treatments?

Researchers are excited about using volatile anesthetics like Isoflurane and Sevoflurane for COVID-19 patients because they offer a unique method of sedation compared to the standard intravenous (IV) sedation typically used in intensive care units. These anesthetics are inhaled rather than administered through an IV, which might allow for more precise control over sedation levels. This inhalation method could potentially reduce the need for IV sedation, helping to minimize associated side effects and complications. Moreover, volatile anesthetics may also possess anti-inflammatory properties, offering additional benefits for managing severe COVID-19 symptoms.

What evidence suggests that this trial's treatments could be effective for patients with lung failure?

Research has shown that inhaled anesthetics like Isoflurane and Sevoflurane can benefit patients on ventilators, especially those with COVID-19. In this trial, participants in the inhaled volatile anesthetic group will receive either Isoflurane or Sevoflurane, depending on hospital availability. Studies have found that Isoflurane reduces the need for other sedative drugs, which is beneficial during drug shortages. Additionally, Sevoflurane has been linked to lower death rates and better patient stability. Both treatments may help reduce lung swelling and improve oxygen levels, allowing patients to recover faster. These inhaled agents could offer a practical solution to current sedation challenges in intensive care. ^{4 6 7 8 9}

Are You a Good Fit for This Trial?

Adults over 18, on mechanical ventilation for severe lung failure possibly due to COVID-19, and expected to need it for at least another day. They should have been sedated via IV for no more than 72 hours and not allergic to the trial drugs. Excluded are those with high brain pressure, severe brain injury, certain lung or neuromuscular conditions, contraindications to specific sedatives, pregnant women or patients unlikely to survive a day.

Inclusion Criteria

You are currently using a breathing machine and will still need it tomorrow.

I am on IV sedation for less than 72 hours to help with mechanical breathing.

I was moved to a trial site and needed more help with breathing within the last 3 days.

Exclusion Criteria

I have a severe brain injury likely to cause prolonged unconsciousness.

Known pregnancy

I might have high pressure inside my skull.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

1 week

Treatment

Participants receive either intravenous or inhaled volatile-based sedation, randomized within 72 hours of sedation start

30 days

Daily visits in ICU

Follow-up

Participants are monitored for safety and effectiveness after treatment, with assessments at 30, 60, 90, and 365 days post-enrollment

12 months

Telephone or database follow-up at specified intervals

Neuro-cognitive and Biomarker Assessment (optional)

Participants have the option to participate in additional neuro-cognitive and biomarker assessments

What Are the Treatments Tested in This Trial?

Interventions

• Isoflurane Inhalant Product
• Sevoflurane inhalant product

Trial Overview The study compares inhaled anesthetics Sevoflurane and Isoflurane as alternatives for IV sedation in ICU patients with respiratory failure. It aims to see if these gases can improve survival rates, reduce time on ventilators and in hospitals by reducing lung inflammation and improving oxygen levels.

How Is the Trial Designed?

Group I: Inhaled - volatile anesthetic Experimental Treatment 2 Interventions

The ICU patient will be randomized to either Isoflurane or Sevoflurane, whichever is available at the hospital. Dosage will be modified as per health care team guidance for the best treatment of the participant.

Group II: Non-randomized Active Control 1 Intervention

In this arm, ICU patients who cannot be randomized will receive inhaled or IV sedation as per available in their unit. This is done to try to obtain the maximum amount of information available from the patients present to our ICUs.

Group III: Standard Care Active Control 1 Intervention

The ICU patient will be randomized to standard of care, which is any IV sedation supplied by the hospital. Dosage will be modified as per health care team guidance for the best treatment of the participant.

Isoflurane Inhalant Product is already approved in United States, European Union, Canada, Japan for the following indications:

Approved in United States as Forane for:

• General anesthesia
• Maintenance of anesthesia

Approved in European Union as Isoflurane for:

• Induction and maintenance of general anesthesia

Approved in Canada as Isoflurane for:

• General anesthesia

Approved in Japan as Isoflurane for:

• General anesthesia

Who Is Running the Clinical Trial?

Sunnybrook Health Sciences Centre

Lead Sponsor

Trials

693

Recruited

1,569,000+

Published Research Related to This Trial

Ustekinumab has been shown to be effective in treating autoimmune conditions like psoriasis and is generally well tolerated and safe in short-term studies.

The review discusses important factors such as the pharmacokinetics of ustekinumab, its safety profile, and considerations for use in pregnancy, highlighting its potential for long-term use despite ongoing investigations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The safety of ustekinumab in psoriasis. Famenini, S., Wu, JJ.[2015]

In a study involving 143 adult patients, sevoflurane was found to allow for a quicker recovery from general anesthesia compared to isoflurane, with shorter times for extubation, eye opening, and command response.

Both sevoflurane and isoflurane demonstrated similar safety profiles, as there were no significant differences in renal and hepatic function before and after surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Maintenance and recovery characteristics of sevoflurane anaesthesia in adult patients. A multicenter, randomized comparison with isoflurane. Ranieri, R., Martinelli, G., Pagani, I., et al.[2018]

In a study of 23 patients with inflammatory bowel disease (IBD) who had a partial or lost response to subcutaneous ustekinumab (SC UST), 82.6% achieved a clinical response after 12 weeks of intravenous (IV) UST maintenance treatment.

The treatment was safe, with no adverse events reported, and 43.5% of patients reached clinical remission, indicating that IV UST can effectively recapture response in patients previously on SC UST.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Intravenous ustekinumab maintenance treatment in patients with loss of response to subcutaneous dosing. Argüelles-Arias, F., Valdés Delgado, T., Maldonado Pérez, B., et al.[2023]

Ustekinumab, recently approved for treating Crohn's disease and ulcerative colitis, can cause immediate infusion reactions in some patients, as observed in three therapy-refractory cases.

Two of the patients who had an infusion reaction also experienced subsequent reactions to subcutaneous injections, highlighting the need for careful monitoring during treatment.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Immediate Infusion Reaction to Intravenous Ustekinumab in Three Crohn's Disease Patients: A Case Report and Review of the Literature. Thomas, PWA., Ferwerda, G., West, RL., et al.[2021]

Four out of 13 sevoflurane vaporizers were contaminated with water and Staphylococcus epidermidis, indicating a potential safety risk in their use.

The contamination was linked to water accumulation in the vaporizers, which can lead to the production of harmful metabolites, including urea and other organic compounds, highlighting the importance of proper maintenance and monitoring of anesthesia equipment.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Sevoflurane Contamination: Water Accumulation in Sevoflurane Vaporizers Can Allow Bacterial Growth in the Vaporizer. Wallace, AW.[2022]

The study demonstrated that a magnetocontrollable sorbent effectively reduced proinflammatory cytokines IL-12 and IL-23 by up to 99.9% in patients with psoriatic arthritis, indicating a strong efficacy in targeting these key inflammatory markers.

The procedure did not significantly alter blood cell counts, suggesting that this method of cytokine removal using Ustekinumab-based sorbents is safe and could be beneficial in managing psoriatic arthritis without adverse effects on blood health.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Sorption of Interleukins 12 and 23 Using the Developed Magnetocontrollable Ustekinumab-Based Sorbent. Gontar, IP., Emelyanova, OI., Rusanova, OA., et al.[2022]

Sevoflurane, an inhalation anesthetic, is available in the U.S. as both a brand (Ultane) and a generic version, with the FDA rating them as therapeutically equivalent despite differences in their manufacturing processes.

Ultane is produced through a single-step process and contains more water (>300 ppm) compared to the generic version, which is made in a three-step process and contains less water (≤130 ppm), potentially affecting stability and efficacy.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Sevoflurane: are there differences in products? Baker, MT.[2018]

The proposed maximum admissible concentrations (MAC) for sevoflurane and isoflurane are 55 mg/m3 (7 ppm) and 32 mg/m3 (4 ppm), respectively, which aim to protect surgical staff from potential health risks associated with these anesthetics.

Establishing these MAC values is crucial as it provides a guideline for employers to assess and manage exposure to these inhalant anesthetics in the workplace, ensuring the safety of healthcare workers.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Assessment of health risk of sevoflurane and isoflurane exposure among surgical staff: a problem for employers]. Kupczewska-Dobecka, M., Soćko, R.[2018]

Desflurane allowed for significantly faster recovery times, specifically in time to eye-opening, compared to sevoflurane and isoflurane, making it a quicker option for ambulatory surgeries.

Isoflurane was found to be the most cost-effective anesthetic agent, with lower overall costs while maintaining comparable safety and recovery profiles to sevoflurane and desflurane.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Randomized Comparison of Isoflurane versus Sevoflurane and Desflurane for Maintenance of Ambulatory Anesthesia. Kurhekar, P., Vinod, K., Krishna, JSD., et al.[2022]

Ustekinumab, an anti-IL-12/IL-23 monoclonal antibody, shows a positive exposure-response relationship in treating moderately to severely active ulcerative colitis, indicating that higher drug exposure correlates with better clinical outcomes such as response and remission.

The pharmacokinetics of ustekinumab were well characterized by a 2-compartment model, and while factors like body weight and sex influenced drug levels, they did not require dose adjustments, supporting the use of a standard dosing regimen for effective treatment.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Population Pharmacokinetics and Exposure-Response Modeling Analyses of Ustekinumab in Adults With Moderately to Severely Active Ulcerative Colitis. Xu, Y., Hu, C., Chen, Y., et al.[2021]

Citations

1. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC8225486/

Comparison of isoflurane and propofol sedation in critically ... In this retrospective study, we compared inhaled sedation with isoflurane to intravenous propofol in invasively ventilated COVID-19 patients ...

2. mdpi.com mdpi.com/2077-0383/11/9/2500

Inhaled Sedation for Invasively Ventilated COVID-19 Patients Isoflurane was the most frequently used volatile agent in COVID-19 patients and allowed a reduction in the use of other sedative and analgesic drugs.

3. mednext.zotarellifilhoscientificworks.com mednext.zotarellifilhoscientificworks.com/index.php/mednext/article/download/131/129/134

The importance of sedation in patients admitted with ... Analgesia and sedation are an integral part of the care provided to critically ill patients with COVID-19. These.

4. outbreak.info outbreak.info/resources/search?q=%22Isoflurane%22

COVID-19 Research Library | Search You searched for "Isoflurane" · Metformin alleviates prolonged isoflurane inhalation induced cognitive decline via reducing neuroinflammation in adult mice.

5. doaj.org doaj.org/article/74358b575bdd4117999c8a6c9de215ab

Standard Sedation and Sedation With Isoflurane in ... Objectives:. To describe sedative and analgesic drug utilization in a cohort of critically ill patients with coronavirus disease 2019 and compare standard.

6. accessdata.fda.gov accessdata.fda.gov/drugsatfda_docs/label/2021/017624s040lbl.pdf

FORANE (isoflurane, USP) liquid for inhalation Isoflurane is a clear, colorless, stable liquid containing no additives or chemical stabilizers. Isoflurane has a mildly pungent, musty, ethereal odor.

7. clinicaltrials.gov clinicaltrials.gov/study/NCT04415060

SedAting With Volatile Anesthetics Critically Ill COVID-19 ... These gases, also called "inhaled agents" can also be used in intensive care units and may have several important benefits for patients and the hospital.

8. osha.gov osha.gov/chemicaldata/850

ISOFLURANE | Occupational Safety and Health ... ISOFLURANE Chemical Identification, Physical Properties, Monitoring Methods Used by OSHA. All sampling instructions above are recommended guidelines.

9. link.springer.com link.springer.com/article/10.1007/s00134-020-06154-8

Inhalational volatile-based sedation for COVID-19 ... Sevoflurane, desflurane or isoflurane can all be used, but isoflurane offers the greatest potency with the lowest dosing requirements for ICU ...