COpeptin in Critically Ill Paediatric and Neonatal Intensive Care Patients and Its Association With Arterial Hypotension. A Single-centre Prospective Observational Study.
Conditions: Arterial Hypotension in Critically Ill Neonatal and Pediatric Patients
Sponsor: Vincenzo Cannizzaro

COpeptin in critically ill 
Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension 
A single-centre prospective observational study 
The COPNIC-Study 
Type of Research Project: 
Research project in which biological material is sampled from humans 
and health-related personal data is collected  
 
Risk Categorisation: 
Risk category A 
 
Project Identifier: 
COPNIC-Study 
 
Project Leader: 
Vincenzo Cannizzaro, MD, PhD 
University Children`s Hospital Zurich 
Steinwiesstrasse 75 
CH-8032 Zurich  
Telefon +41 44 266 7111 
Vincenzo.cannizzaro@kispi.uzh.ch 
www.kispi.uzh.ch  
 
Health condition / problem 
Critical illness and hypotension in paediatric and neonatal intensive 
care patients 
 
Project Duration 
36 months 
  
Project Plan Version and Date: 
2.2 17/08/2017 
 
 
ACCESS TO RESEARCH DOCUMENTS 
The information contained in this document is confidential and the property of the project leader. The information 
may not - in full or in part - be transmitted, reproduced, published, or disclosed to others than the applicable 
Competent Ethics Committee(s) and Regulatory Authority (ies) without prior written authorisation from the 
sponsor except to the extent necessary to obtain informed consent from those who will participate in the study. 
 
 
 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 1 of 27 

 
 
TABLE OF CONTENTS 
SYNOPSIS (SUMMARY) ........................................................................................................................ 4 
ABBREVIATIONS ................................................................................................................................... 8 
SCHEDULE OF ASSESSMENTS (FLOW OF RESEARCH PROJECT) ............................................... 9 
1. 
ADMINISTRATIVE STRUCTURE ................................................................................................. 10 
2. 
ETHICAL AND REGULATORY ASPECTS .................................................................................. 11 
2.1 
Ethical Conduct of Study .............................................................................................................. 11 
2.2 
Risk categorisation ....................................................................................................................... 11 
2.3 
Ethics Committee (EC) and Competent Authorities (CA), FOPH ................................................ 11 
2.4 
Participant Information and Informed Consent ............................................................................ 11 
2.5 
Participant privacy and safety ...................................................................................................... 11 
2.6 
Early termination of project .......................................................................................................... 12 
2.7 
Amendments, Changes ................................................................................................................ 12 
3. 
INTRODUCTION ............................................................................................................................ 12 
3.1 
Background .................................................................................................................................. 12 
3.2 
Rationale for the research project ................................................................................................ 13 
3.3 
Risk-Benefit Assessment ............................................................................................................. 14 
4. 
OBJECTIVES, ENPOINTS/OUTCOMES AND OTHER STUDY VARIABLES ............................ 14 
4.1 
Objectives..................................................................................................................................... 14 
4.2 
Primary and secondary endpoint/outcome(s) .............................................................................. 15 
4.3 
Other study variables ................................................................................................................... 18 
5. 
PROJECT DESIGN ....................................................................................................................... 18 
5.1 
Type of research and general project design............................................................................... 18 
5.2 
Procedures ................................................................................................................................... 18 
5.3 
Recruitment and Screening.......................................................................................................... 19 
5.4 
Methods of minimising bias .......................................................................................................... 19 
6. 
PROJECT POPULATION .............................................................................................................. 19 
6.1 
Inclusion criteria ........................................................................................................................... 19 
6.2 
Exclusion criteria .......................................................................................................................... 19 
6.3 
Criteria for withdrawal / discontinuation of participants ................................................................ 19 
7. 
PROJECT ASSESSMENTS .......................................................................................................... 19 
7.1 
Project flow chart(s) / table of procedures and assessments ...................................................... 19 
7.2 
Assessments of primary endpoint/outcome ................................................................................. 19 
7.3 
Assessment of secondary endpoint/outcome(s) .......................................................................... 20 
7.4 
Assessment of other study variables ........................................................................................... 20 
7.5 
Assessment of safety and reporting ............................................................................................. 20 
7.5.1 Definition of Serious Events (SEs) ...................................................................................... 20 
7.5.2 Assessment and Documentation of SEs............................................................................. 21 
7.5.3 Reporting of SEs, Safety and Protective Measures ............................................................ 21 
8. 
STATISTICAL METHODOLOGY .................................................................................................. 21 
8.1 
Determination of Sample Size...................................................................................................... 21 
8.2 
Planned analysis .......................................................................................................................... 22 
8.2.1 Datasets to be analysed ..................................................................................................... 22 
8.2.2 Handling of missing data ..................................................................................................... 23 
8.2.3 Ancillary analysis ................................................................................................................. 23 
8.2.4 Deviations from the original statistical plan ......................................................................... 23 
9. 
DATA AND QUALITY MANAGEMENT ........................................................................................ 24 
9.1 
Data handling and record keeping / archiving.............................................................................. 24 
9.2 
Confidentiality, Data Protection .................................................................................................... 24 
9.3 
Coding .......................................................................................................................................... 24 
9.4 
Archiving and Destruction ............................................................................................................ 24 
10. PUBLICATION AND DISSEMINATION POLICY.......................................................................... 24 
10.1 Publication of results .................................................................................................................... 24 
10.2 Data sharing ................................................................................................................................. 25 
11. FUNDING AND SUPPORT ............................................................................................................ 25 
12. INSURANCE .................................................................................................................................. 25 
13. REFERENCES ............................................................................................................................... 25 
 
 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 3 of 27 

 
SYNOPSIS (SUMMARY) 
Project Leader (or 
Sponsor) 
PD Dr. med. Vincenzo Cannizzaro, PhD 
Universitäts-Kinderspital Zürich 
Steinwiesstrasse 75 
CH-8032 Zürich 
Telefon +41 44 266 7111 
Vincenzo.cannizzaro@kispi.uzh.ch 
www.kispi.uzh.ch  
Project Title: 
Zusammenhang zwischen dem neuen Blutwert Copeptin und niedrigem 
Blutdruck bei Kindern und Jugendlichen auf der Intensivstation 
Short Title / Project 
ID: 
COPNIC-Study 
KEK 2017-00451 
Project Plan Version 
and Date: 
2.2 17/08/2017 
Risk categorisation: 
Risiko Kategorie A  
Type of Research: 
Forschungsprojekt, während dessen biologisches Material von Menschen 
entnommen wird und gesundheitsbezogene persönliche Daten gesammelt 
werden. 
Project design: 
Prospektive Beobachtungsstudie an einem Zentrum 
Background and 
Rationale: 
Auf einer Intensivstation leiden kritisch kranke pädiatrische Patienten häufig 
unter niedrigem arteriellem Blutdruck. Dies kann verschiedene Gründe haben 
und in verschiedenen klinischen Situationen mit Herz-Kreislauf- und 
Atemversagen auftreten, z. B. im septischen Schock, bei peripartaler Asphyxie, 
bei Schädel-Hirn-Trauma und nach verschiedenen Operationen. Die 
intensivmedizinischen Standardbehandlungen für arterielle Hypotension 
bestehen aus intravenösen Volumengaben und Katecholamintherapie. Beide 
Behandlungen können sehr effektiv sein, bergen aber auch schwerwiegende 
Risiken für Komplikationen: Lungenödem, verlängerte Beatmungszeit, 
verlängerter Aufenthalt auf der Intensivstation, Arrhythmien, erhöhter 
Sauerstoffbedarf des Herzmuskels, etc. Es ist wünschenswert, die Volumen- und 
Katecholamingaben sinnvoll einzuschränken, um die Nebenwirkungen zu 
reduzieren. 
In den letzten Jahren konnte gezeigt werden, dass ein Teil der 
intensivmedizinischen Patienten einen zumindest vorrübergehenden Mangel des 
körpereigenen, stark vasoaktiven Hormons Vasopressin aufweist und dass diese 
Patienten von einer intravenösen Vasopressingabe profitieren könnten. Kinder 
und Jugendliche sind bisher nur in wenigen und kleinen Studien untersucht 
worden und es gibt bisher in der klinischen Routine keine etablierte Möglichkeit, 
Patienten mit einem Vasopressinmangel zu erkennen.  
In dieser Studie wird zu diesem Zweck Copeptin im Blut gemessen, da 
Vasopressin zum einen selbst schwer zu messen ist, und zum anderen, weil 
Copeptin äquimolar zum Vasopressin in die Blutbahn ausgeschüttet wird. Mittels 
Copeptin-gesteuerter intravenöser Vasopressintherapie bei Patienten mit einem 
Mangel an körpereigenem Vasopressin könnte die risikoreiche Volumen- und 
Katecholamintherapie gezielt unterstützt werden und Flüssigkeitsvolumen und 
Katecholamine eingespart werden 
Objective(s): 
In dieser prospektiven Beobachtungstudie wird der Verlauf des Biomarkers 
Copeptin im Blut kritisch kranker Kinder und Jugendlicher untersucht. Speziell 
werden die Assoziationen mit arterieller Hypotension und verschiedenen 
Covariablen/Krankheiten geprüft, um Rückschlüsse auf einen relevanten 
Vasopressinmangel zu ziehen. 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 4 of 27 

 
Endpoint(s): 
Primärer Endpunkt 
Mittlere Veränderung von Blut-Copeptinspiegeln bei kritisch kranken Kindern 
und Jugendlichen mit arterieller Normo- und Hypotension über 48 Stunden nach 
Aufnahme auf die Intensivstation des Kinderspitals Zürich. In einem zweiten 
Schritt werden der Verlauf und die Variabilität der Blut-Copeptinspiegel über 
einen Zeitraum von bis zu 7 Tagen charakterisiert.  
 
Es werden Assoziationen mit folgenden klinischen Co-Variablen geprüft: 
• Arterieller Blutdruck 
• Septischer Schock 
• Herzinsuffizienz 
• Schädelhirntrauma, Hirntumor und/oder intrakranielle Operation 
• Perinatale Asphyxie 
• Krankheitsschwere 
• Alter 
 
Sekundäre Endpunkte 
• Prädiktive Assoziationen von Copeptin mit folgenden klinischen Outcome-
Parametern: 
- 
Dauer des Aufenthaltes auf der Intensivstation. 
- 
Dauer der respiratorischen Unterstützung 
- 
Dauer und Dosis der Katecholamintherapie 
- 
Todesrate bei 28 Tagen  
• Dynamischer Zusammenhang zwischen Blutdruck, Copeptinspiegeln und 
Katecholamintherapie. 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 5 of 27 

 
Inclusion / Exclusion 
criteria: 
Einschlusskriterien: 
Alle kritisch kranken pädiatrischen Patienten unabhängig von deren Alter, 
Erkrankung oder Krankheitsschwere kommen für den Einschluss in diese Studie 
in Frage. Die Blutcopeptinwerte von Patienten mit arterieller Hypotension werden 
mit den Werten von Patienten verglichen, die einen normalen Blutdruck 
aufweisen und keine medikamentöse Blutdruckunterstützung benötigen. Diese 
letztgenannten Patienten werden aufgrund fehlender international anerkannter 
Normalwerte zur Berechnung der Copeptin-Referenzbereiche benötigt. Es 
werden daher alle Patienten im genannten Altersbereich, die auf die 
Intensivstation des Kinderspitals Zürich eintreten, in diese Studie eingeschlossen, 
sofern die folgenden Einschlusskriterien und keines der Ausschlusskriterien 
erfüllt sind: 
• 
Alter: Erster Lebenstag bis <18 Geburtstag. 
• 
Fähigkeit der für das Kind sorgeberechtigten Person oder der/des 
Jugendlichen (falls ≥14 Jahre), mündliche und schriftliche Informationen 
sowie die Einwilligungserklärung in Deutsch zu verstehen. 
Ausschlusskriterien: 
• 
Sorgeberechtigte Person oder Patient(-in) (falls ≥14 Jahre) nicht fähig, 
mündliche und schriftliche Informationen sowie die Einwilligungserklärung 
in Deutsch zu verstehen. 
• 
Unmöglichkeit der Einwilligung aus anderen Gründen (beispielsweise 
Abwesenheit von sorgeberechtigten Personen oder tiefe Sedation der/des 
Jugendlichen (falls ≥14 Jahre) für >24 Stunden bei Abwesenheit eines 
gesetzlichen Vertreters). 
• 
Ablehnen der Studienteilnahme durch die sorgeberechtigte Person oder 
den/die Jugendliche (falls ≥14 Jahre und sediert für < 24h). 
In 
diese 
Studie 
werden 
vulnerable 
Patientengruppen 
eingeschlossen: 
Neugeborene, Kinder und Jugendliche. Zum Teil sind diese Patienten nicht 
auskunftsfähig und die Eltern oder die gesetzlichen Vertreter müssen an ihrer statt 
in die Studie einwilligen. 
Der Einschluss der genannten Patienten ist unumgänglich, da zum einen die Daten 
zu pädiatrischen Patienten bisher nur in geringem Ausmaß vorhanden sind. Zum 
anderen leiden die jüngeren Patienten besonders stark unter den Nebenwirkungen 
der Katecholamin- und Flüssigkeitstherapie. Die Entwicklung eines Biomarkers 
zur Identifikation von Patienten, die auf eine intravenöse Vasopressingabe 
ansprechen und somit weniger Katecholamin- und Flüssigkeitstherapie 
benötigen, ist besonders bei diesen Patientengruppen wünschenswert. 
Project assessments, 
procedures: 
Während der Routinebehandlung kritisch kranker Kinder und Jugendlicher auf 
der Intensivstation des Kinderspitals Zürich wird zu verschiedenen Zeitpunkten 
(Aufnahme, 12, 24, 48, 96, 168 Stunden) das Blutcopeptin der Patienten 
gemessen. Der Zeitpunkt der Blutentnahme wird durch anderweitig medizinisch 
indizierte Blutentnahmen festgelegt, damit keine zusätzlichen Manipulationen an 
zentralvenösen oder arteriellen Kathetern und keine zusätzlichen schmerzhaften 
Blutentnahmen erforderlich werden. Es wird die Assoziation des Copeptins mit 
verschiedenen klinischen Diagnosen, Vital- und Laborparametern untersucht, die 
im klinischen Alltag alle open-label vorhanden sind. Diese Co-Variablen werden 
auf den Papier-Case-Report-Forms notiert und sind zusammenfassend im 
SCHEDULE OF ASSESSMENTS, Seite 11 dieses Protokolls, einzusehen. 
Number of 
Participants: 
Diese Studie erreicht eine Power von 0.8 bei einer Effektstärke von 0.36 und 
einem Signifikanzniveau von 0.05 bei 62 Patienten (siehe unten; Statistical 
Analysis incl. Power Analysis). Da innert den ersten 48 Stunden eine Drop-Out-
Rate von 60% durch geplante Entlassung von der Intensivstation zu erwarten ist 
und bis zu 10% der Copeptinwerte außerhalb des Messbereichs liegen, muss die 
Patientenzahl entsprechend höher angesetzt werden. Insgesamt werden daher:  62 
x 2.5 x 1.1 = 170 Patienten in diese Studie eingeschlossen. 
Project Duration, 
schedule: 
Gesamtdauer: 36 Monate 
Patienteneinschlussphase: 18 Monate (01.10.2017 - 31.03.2018). 
Datenanalyse, Konferenzen und Publikation: 18 Monate (01.04.2019-
30.09.2020). 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 6 of 27 

 
Project Centre(s): 
Universitäts-Kinderspital Zürich 
Steinwiesstrasse 75 
CH-8032 Zürich 
Statistical 
Considerations: 
Diese Studie ist eine Beobachtungstudie mit zu erwartenden deskriptiven 
Ergebnissen.  
Die Studie wird gepowert für den primären Endpunkt, der mittleren Veränderung 
des Blut-Copeptins in den ersten 48 Stunden nach Aufnahme auf die 
Intensivstation bei kritisch kranken Kindern und Jugendlichen.  
Folgende Faktoren sind dabei zu berücksichtigen: 
• 
Basierend auf den verfügbaren publizierten Daten wird bei 48 Stunden eine 
mittlere Copeptin-Differenz (zum Aufnahmezeitpunkt; d) von 0.3 ng/ml 
(Inter-Quartilenbereich: 1.1 ng/ml) erwartet. Daraus ergeben sich die 
Standardabweichung (sd) von 0.82 ng/ml und die Effektstärke (d/sd) von 
0.36. 
• 
60% der Patienten werden potentiell innert 48 Stunden verlegt. 
• 
90% der gewonnenen Werte liegen im messbaren Bereich.  
• 
Mit den Voraussetzungen 0.8 Power, Signifikanzniveau 0.05, Effektstärke 
0.36, 60 % Drop-out, 10% außerhalb des messbaren Bereichs errechnet sich 
eine Patientenzahl von 170 Patienten. 
Other 
methodological 
Considerations: 
Alle eingeschlossenen Patienten werden in die Analyse für den primären 
Endpunkt aufgenommen. 60% der Patienten der Intensivstation werden innert 48 
Stunden verlegt, daher muss die Patientenzahl entsprechend erhöht werden. Von 
besonderem Interesse sind darüber hinaus die Patienten, die länger als 48 Stunden 
hospitalisiert bleiben, dies sind in der Regel schwer kranke Patienten. Daher 
werden zunächst die Blut- Copeptin-Werte aller eingeschlossenen Patienten 
innert den ersten 48 Stunden analysiert und in einem zweiten Schritt die Copeptin-
Werte der Patienten analysiert, die bis zu 7 Tagen bleiben (13% aller Patienten 
bleiben länger als 7 Tage auf der Intensivstation des Kinderspital hospitalisiert). 
Risk-Benefit 
statement: 
Das Wesen dieser Studie besteht aus einem Vergleich von Blut-Copeptin-Werten 
mit routinemäßig vorhandenen klinischen Parametern. Die entnommene 
Blutmenge (600 µl) ist nicht relevant für die Patientenpopulation. Für dieses 
Projekt werden alle geplanten Blutentnahmen zusammen mit anderweitig 
medizinisch indizierten Blutentnahmen durchgeführt. Es werden keine 
zusätzlichen Blutentnahmen durchgeführt, um keine zusätzlichen Manipulationen 
an arteriellen oder zentralvenösen Kathetern mit erhöhtem Infektionsrisiko zu 
verursachen. Des Weiteren wird auf zusätzliche invasive Blutentnahmen 
verzichtet, um keine zusätzlichen Schmerzen zu verursachen.  
Die Belastung der Patienten durch die Studie wird als gering eingeschätzt. 
Die eingeschlossenen Patienten profitieren nicht von der Studie, können aber 
potentiell mithelfen, in Zukunft eine gezielte Unterstützung von schwerkranken, 
hypotensiven Patienten durch Vasopressin zu fördern und somit den risikoreichen 
und schädlichen Gebrauch von Katecholaminen und Flüssigkeit zu vermindern.  
 
 
 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 7 of 27 

 
ABBREVIATIONS 
DoH 
Declaration of Helsinki 
EC 
Ethics Committee 
EGEP 
Essentials of Good Epidemiological Practice  
FOPH 
Federal Office for Public Health  
HRA 
Federal Act on Research involving Human Beings (Human Research Act, HRA) 
HRO 
Ordinance on Human Research with the Exception of Clinical Trials (Human 
Research Ordinance, HRO) 
ID 
Identification 
IIT 
Investigator-initiated Trial 
SE 
Serious event 
STROBE 
PIM 
SAPS 
CRIB 
ICU 
PaO2 
PaCO2 
CT 
ALT 
MRI 
AVP 
Strengthening the reporting of observational studies in epidemiology 
Paediatric Index Of Mortality 
Simplified Acute Physiology Score 
Clinical Risk Index for Babies 
Intensive Care Unit 
PaO2 Partial arterial oxygen pressure 
PaCO2 Partial arterial carbon dioxide pressure 
Computed tomography 
Alanin-Transaminase 
Magnetic Resonance Imaging 
Arginine-Vasopressin 
 
 
 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 8 of 27 

 
SCHEDULE OF ASSESSMENTS (FLOW OF RESEARCH PROJECT) 
Project Periods 
 
 
 
 
If patients still in ICU 
Time (hours) 
Admission ICU 
12* 
24* 
48* 
96* 
168* 
 
Information, Informed Consent 
x 
 
 
 
 
 
In- /Exclusion Criteria 
x 
 
 
 
 
 
Age (years + months); if neonatal (<28 d): postnatal days + 
postconceptional age 
x 
 
 
 
 
 
Diagnosis 
x 
 
 
 
 
 
Disease-Severity-Scoresa 
x 
 
 
 
 
 
Operation, perioperative parametersb 
x 
x 
x 
x 
x 
x 
Weight 
x 
 
 
 
 
 
Sex 
x 
 
 
 
 
 
Primary Variables assessment 
Blood sample for copeptin (600 µl) 
x 
x 
x 
x 
x 
x 
Arterial blood pressure 
x 
x 
x 
x 
x 
x 
Secondary Variables assessment 
Vital parametersc 
x 
x 
x 
x 
x 
x 
Respiratory support 
x 
x 
x 
x 
x 
x 
Vasoactive Drugs 
x 
x 
x 
x 
x 
x 
Other Drugs 
x 
x 
x 
x 
x 
x 
Fluid administration/24h each day 
x 
x 
x 
x 
x 
x 
Laboratory valuesd 
x 
x 
x 
x 
x 
x 
Neurological/neonatal findingse 
x 
x 
x 
x 
x 
x 
Organ dysfunction/mechanical resuscitation 
x 
x 
x 
x 
x 
x 
Serious (Adverse) Events/Death 
x 
x 
x 
x 
x 
x 
Discharge date from ICU/Hospital 
When applicable 
a) Paediatric Index Of Mortality, PIM II; Simplified Acute Physiology Score, SAPS II; Clinical Risk Index for Babies, CRIB II 
b) Preoperative medication, anaesthetics, type of surgery. If cardiac surgery in addition: cardiac lesion, echocardiographic and cardiac catheter results, periods of cardiopulmonary 
bypass, cross clamping, deep hypothermic arrest, modified ultrafiltration, postoperative echocardiographic results.  
c) Respiratory rate, peripheral oxygen saturation, arterial oxygen saturation, heart rate, peripheral pulses, capillary refill, urine output. 
d) Sodium, potassium, chloride, calcium, troponin, creatine kinase, creatine kinase MB, pH, partial arterial oxygen pressure (PaO2), partial carbon arterial 
carbon dioxide pressure (PaCO2), base deficit, arterial lactate, glucose, alanine transaminase (ALT), creatinine, C-reactive protein, haemoglobin, white blood 
cell count, total bilirubin; all if medically indicated. 
e) Glasgow Coma Scale, CT-findings (abnormal cisterns, midline shift >5mm, traumatic subarachnoidal hemorrhage), seizures, intracranial and cerebral perfusion pressure (if 
invasively monitored); Apgar-score, arterial umbilical cord pH, results of neurological imaging (cranial ultrasound and/or MRI), and performance of neonatal cooling as 
prevention of neurological damage. 
* Exact time points will be determined by other medical indications of blood sampling. 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 9 of 27 

 
1. ADMINISTRATIVE STRUCTURE  
 
Project Leader  
 
Name: Vincenzo Cannizzaro, MD, PhD 
Address: University Children`s Hospital Zurich 
Steinwiesstrasse 75 
CH-8032 Zurich 
Email: Vincenzo.cannizzaro@kispi.uzh.ch 
Phone: +41 44 266 7111 
Fax: +41 44 266 7168 
 
 
Project site(s) and responsible researcher: 
Institution: University Children`s Hospital Zurich  
Name: Philipp Baumann, MD 
Address: Steinwiesstrasse 75, CH-8032 Zurich   
Email: philipp.baumann@kispi.uzh.ch 
Phone: +41 44 266 7111 
Fax: +41 44 266 7168 
 
Key Persons involved in research project: 
 
Name: Markus Deisenberg, MD 
Address: Steinwiesstrasse 75, CH-8032 Zurich 
Email: kevin.schmid@kispi.uzh.ch 
Phone: +41 44 266 7111 
Fax: +41 44 266 7168 
 
Other personnel 
 
 
Biostatistician: 
Name: Verena Gotta 
Address: Pediatric Pharmacology and 
Pharmacometrics 
University of Basel Children’s Hospital 
Spitalstrasse 33, CH-4056 Basel  
Email: Verena.Gotta@ukbb.ch  
Phone: + 41 61 704 1212 
 
 
Laboratory: 
Institution: Institute of Clinical Chemistry 
University Children`s Hospital Zurich 
Name: Martin Hersberger, PhD 
Address: Steinwiesstrasse 75, 8032 Zurich 
Email: martin.hersberger@kispi.uzh.ch 
Phone: +41 44 266 75 41 
Fax: +41 44 266 71 69 
 
 
 
 
 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 10 of 27 

 
2. ETHICAL AND REGULATORY ASPECTS  
2.1 Ethical Conduct of Study 
The research project will be carried out in accordance to the research plan and with principles 
enunciated in the current version of the Declaration of Helsinki (DoH), the Essentials of Good 
Epidemiological Practice issued by Public Health Schweiz (EGEP), the Swiss Law and Swiss 
regulatory authority’s requirements as applicable, the full responsibility for this lies with the project 
leader. The EC and regulatory will be informed about project start and termination.  
2.2 Risk categorisation  
This is an observation study with risk category A involving human beings (critical ill children) without any kind 
of medical intervention. Blood samples will be taken during regular clinical blood sampling to measure blood 
levels of copeptin. Blood sampling and data storage are considered to be of minor clinical and personal relevance 
for the study patients. 
2.3 Ethics Committee (EC) and Competent Authorities (CA), FOPH 
Kantonale Ethikkommission Zürich 
Stampfenbachstrasse 121 
8090 Zürich 
2.4 Participant Information and Informed Consent 
All patient care takers and adolescents (if age≥14 years) have to give written informed consent. Informed consent 
forms will be only available in German. For enrolment, patients, parents, family members or other care takers must 
have sufficient knowledge of German to understand the instructions, given by their treating intensive care 
specialist. Written informed consent for study inclusion should be obtained from patients (if ≥ 14 years of age), 
patients` parents or care takers before first study relevant blood sample is taken and before first patient data are 
recorded. 
In this study we have to include vulnerable patients, please see chapter 3.3 risk-benefit assessment. 
This study may include patients, who themselves or whose caretakers may not be able to give written informed 
consent in emergency situations. This may be due to acute clinical deterioration, resuscitation and/or sedation of 
the patients. Further, care takers may not be present or accountable for formal medical explanations and may not 
be able to give informed consent at the time of intensive care unit admission due to the deterioration of their child. 
In this case, blood samples for copeptin will be taken, but not analyzed. As soon as possible, but latest 24 hours 
following intensive care unit admission, written informed consent will be obtained from care takers, if patient < 
14 years or if patient ≥ 14 years and sedated for more than 24 hours. If the adolescent (≥14 years of age) stays 
sedated or unable to give informed consent for more than 24 hours, the presumptive will of the adolescent has to 
be taken into account by the legal care takers when giving informed consent in her/his place. Written informed 
consent will be obtained from the patient her-/himself, if ≥ 14 years and sedated for less than 24 hours in agreement 
with HFG Art. 30, Abs. 2. If a legal care taker gives informed consent in place of an adolescent (≥14 years of age), 
the informed consent must be obtained from the adolescent her-/himself as soon as the adolescent is able to give 
consent her-/himself. If the adolescent is not willed to give consent, all data and blood products obtained until then 
will be destroyed in this case. The volume of blood necessary for the copeptin analysis (600 µl each sample) is not 
relevant for any age group including neonates. The additional clinical data needed for primary and secondary 
endpoint assessment is open-label. Study relevant data is available in medical files and electronic patient data 
management systems of the intensive care ward anyway. In addition, copeptin analyses will be performed only for 
blood samples from patients with written informed consent using a pooled batch of blood samples several weeks 
later. 
In case written informed consent cannot be obtained within 24 hours after admission, the patient will not be 
included in the study, all blood samples will be destroyed and no patient data will be analyzed (in agreement with 
HFG Art. 31 Abs.1+2). 
The patients included in this study will not directly benefit from the study. However, the expected added scientific 
and clinical value has the potential to significantly improve future patient safety and management in emergency 
and critical care situations. 
2.5 Participant privacy and safety  
The Project Leader affirms and upholds the principle of the participants’ right to dignity, privacy and health and 
that the project team will comply with applicable privacy laws. Especially, anonymity of the participants will be 
guaranteed when presenting data at scientific meetings or publishing in scientific journals.  
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 11 of 27 

 
Individual participant medical information obtained as a result of this research project is considered confidential 
and disclosure to third parties is prohibited. Participant confidentiality will be further ensured by utilising 
identification code numbers to correspond to medical information in the computer files. 
For data verification purposes, authorised representatives of the Sponsor, a competent authority or an ethics 
committee may require direct access to parts of the medical records relevant to the project, including participants’ 
medical history. 
According to HFG Art. 30 Abs. 1 lit. c it is necessary to obtain written confirmation of a physician not related to 
the study, that the personal and legal rights of the unconscious patient are granted. The volume of blood necessary 
for the copeptin analysis (600 µl each sample) is not relevant or harmful for any age group. Therefore, it is deemed, 
that it is not necessary to obtain the mentioned written confirmation by a physician not related to the study. 
 
2.6 Early termination of project 
This study compares blood values with clinical conditions in an observational manner. Given the small blood 
volume sampled for each copeptin measurement (600 µl) serious adverse events related to the study and leading 
to early termination of the study are highly unlikely. Therefore, no termination criteria have to be defined. 
However, the premature end or interruption of the research project for any reason will be reported to the EC 
within 90 days by the project leader upon completion of the project (HRO Art. 22).  
2.7 Amendments, Changes 
Significant changes to the project plan will have to be approved by the EC (amendments, if applicable according 
HRO Art. 18).  
The Project Leader will submit to the EC any application documents specified in Annex 2, which are affected by 
the change. At the same time, the project leader will provide information on the reasons for the change. 
Substantial amendments are only implemented after approval of the EC.  
3. INTRODUCTION  
3.1 Background  
The aim of this prospective observational study is to characterize the course and progression of the biomarker 
copeptin in critically ill neonates and children. Copeptin values have the potential to be associated with outcome 
and to serve as a therapeutic guide for exogenous vasopressin administration in severe arterial hypotension and 
shock. 
 
Paediatric intensive care patients very often suffer severe arterial hypotension in various clinical situations with 
cardiac and respiratory failure, e.g. septic shock, asphyxia, brain injury, and after several types of operations. 
Septic shock is associated with a very high mortality up to 50% mainly due to an excessive rate of hypoperfusion-
related multiorgan dysfunction (up to 80% in severe sepsis or septic shock)1. Treatment for shock in general 
includes fluid and catecholamine administration to maintain adequate blood flow and sufficient oxygen transport 
to peripheral tissues2-6. Fluid resuscitation may lead to volume overload and pulmonary edema bearing additional 
risks7. In addition, large volumes of fluids administered over a short period of time may lead to heart failure8. 
Though catecholamines deliver strong fluid sparing arterial pressure support, they can place the patient with 
instable cardiovascular state at risk for severe complications (i.e. arrhythmia, right and left ventricular after load 
augmentation, reduced tissue blood flow)9-12.  
 
In recent years, several authors have reported the use of intravenous vasopressin in addition to or instead of 
standard antihypotensive treatment6,13-20. Vasopressin is not a catecholamine but a natural endogenous hormone 
with less toxic side effects. It may help to reduce fluid and catecholamine use. Its main endogenous function is 
maintenance of water- and electrolyte balance, as renal V2-Arginine-Vasopressin (AVP) receptors in the collecting 
duct mediate water reabsorption via induction of intracellular cAMP (Cyclic adenosine monophosphate) 
production and reversible translocation of the water channel “aquaporin 2” from cytoplasmic vesicles to the apical 
cell membrane21. But in addition, it has strong dose-dependent vasoconstrictive effects on the peripheral vessels 
mediated via the V1-vascular AVP-receptor22.  
 
The treatment of arterial hypotension with exogenous vasopressin has been proven to be safe and effective in 
adults, especially in septic vasodilatory shock as shown in a recent metaanalysis23. Following the first successful 
adult case reports, research activity on vasopressin treatment in children and adolescents augmented, but results 
so far are not as clear as in adults.  
 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 12 of 27 

 
Studies in children and neonates could demonstrate that exogenous AVP-administration (or administration of its 
long-lasting analogon terlipressin) can be effective to reduce catecholamine requirements and catecholamine-
related side effects15,24. In addition, it is safe also in very vulnerable patients as extremely low birth weight infants 
(i.e. birth weight <1000g)25. Therefore, the exogenous AVP-use in neonates suffering arterial hypotension 
increases Europe-wide26. However, not all children treated with vasopressin reacted with an adequate rise of blood 
pressure17,18,27. An explanation may be that most paediatric patients (70%) react to critical cardiovascular situations 
with a strong elevation of endogenous vasopressin lasting up to 120 hours in vasodilatory shock28,29. This may at 
least partly explain the ability of children to maintain high blood pressure longer than adults in the early phase of 
beginning shock. Those patients with high endogenous AVP levels do not benefit from additional exogenous 
vasopressin and intravenous vasopressin treatment would be futile30-32. But a fraction of paediatric patients (30%), 
adolescents and children, show rather low endogenous vasopressin levels on several occasions including septic 
and hypovolemic shock. Exogenous vasopressin infusion seemed to be especially helpful for supporting blood 
pressure in those children, whose endogenous vasopressin levels were low (i.e. endogenous vasopressin 
insufficiency), but numbers of children identified so far differ, as pediatric studies are small13,27,30. 
 
Clinical identification of endogenous AVP-deficiency is difficult so far, as no clinical parameters help to establish 
the diagnosis of AVP-deficiency. In this situation, a blood biomarker indicating AVP-deficiency could be a 
solution to this problem. The measurement of endogenous AVP levels would be ideal for the identification of 
individuals in need of additional exogenous AVP, but measurement of endogenous blood AVP is not suitable for 
clinical use for the following reasons. First, laboratory assessment of endogenous vasopressin itself is time 
consuming and cumbersome due to its instable character in vivo (half life 24 minutes) and ex vivo, even frozen at 
-20°C33,34. Second, a large fraction of endogenous vasopressin is platelet-bound, potentially causing erroneous 
measurements35. Therefore, actual research activity focus on the simplified approach to measure blood copeptin 
levels instead of vasopressin. Copeptin is the 39-amino acid long C-terminal portion (C-terminal proAVP, CT-
proAVP) of pre-provasopressin. It is cleaved in a 1:1 ratio to vasopressin from the precursor hormone pre-
provasopressin in the hypothalamus and then released into the portal circulation of the neurohypophysis. The 
endogenous function of copeptin is unclear today. It is stable at room air for 7 days and up to 14 days when cooled 
at 4°C and therefore much more suitable for routine clinical use36. It correlates well with endogenous AVP levels 
in adults, especially in non-septic cases37-39. In children, the correlation to AVP was not favourable in septic shock, 
but excellent in young patients undergoing open heart surgery involving cardiopulmonary bypass27,40. But again, 
numbers in children are small. Furthermore, copeptin has been recognized as an excellent biomarker for non-
favourable outcome in a number of pathologies and for stress- and severity of disease-assessment in children41-44 
as well as in adults45-48. As data on copeptin in the paediatric population are derived from small and observational 
studies so far, general further insight into copeptin dynamics in critically ill children and adolescents would be 
desirable for the evaluation of potential clinical use. 
 
This study is designed to investigate the natural course and variability of copeptin concentrations in critically ill 
children and neonates. Specifically, this study aims to investigate patient characteristics that are associated with 
both arterial hypotension and low endogenous copeptin levels, and to explore the association of copeptin levels 
with clinical outcomes. This may allow identifying patients that could benefit the most from a copeptin-guided 
exogenous vasopressin administration as treatment of arterial hypotension. The individual reaction to exogenous 
vasopressin treatment will however not be investigated in this observational study, which would be subject to a 
follow-up interventional trial. 
3.2 Rationale for the research project 
Based on the background described above, the rationale for this study can be summarized as followed. 
1) Many critically ill children and neonates need intensive care therapy to maintain adequate blood flow and 
arterial blood pressure. 2) The side effects of abundant fluid administration and catecholamine therapy may be 
harmful for patients in critical care. An additional fluid and catecholamine sparing therapy is desirable. 3) Some 
patients with persistent vascular hypotension show low endogenous vasopressin levels. 4) These patients have to 
be identified to administer exogenous vasopressin. 5) Identification of these patients can only be achieved via 
determination of the stable vasopressin-by-product copeptin rather than via direct laboratory assessment of the 
instable endogenous vasopressin.  
 
Accurate identification of patients with persistent low vasopressin/copeptin levels would facilitate future 
individual vasopressin therapy to support and replace, at least in part, catecholamines and fluids in severe arterial 
hypotension and shock. 
As numbers studied for the correlation of copeptin and arterial hypotension in paediatric and neonatal critical care 
settings are small, this prospective observational study has to be performed.  
The actual effect of exogenous vasopressin therapy in patients with low blood copeptin levels will have to be tested 
in a follow-up interventional trial.  
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 13 of 27 

 
3.3 Risk-Benefit Assessment  
The study period will cover up to 168 hours in which a maximum of 6 blood samples (minimum 600 µl each) from 
peripheral venous lines or central venous and arterial catheters will be analysed for baseline copeptin distribution. 
The required amounts of blood volume for analyses are clinically not relevant for any age group. As critically ill 
patients frequently require invasive arterial blood pressure monitoring and central venous access for fluid and 
medicament administration, the required catheters for blood withdrawal are generally in place. Importantly, each 
study blood withdrawal will be grouped together with otherwise medically indicated blood withdrawals, causing 
no additional catheter manipulation, pain or harm for the patient. The comparison of blood copeptin and arterial 
hypotension will define the primary endpoint. 
 
All further laboratory parameters proposed in “Schedule of Assessments (Flow of Research Project)” are 
considered to be secondary endpoints. Analyses of these laboratory values will only be included in the study, if 
their sampling is indicated for any other medical reason. 
 
Children and neonates included in this study do not directly benefit from the study. However, the recruited patients 
help to identify future patient cohorts, which could benefit from individualized vasopressin administration 
supporting and replacing at least a part of the current standard fluid and catecholamine therapy in hypotension and 
shock. Moreover, the potential association between copeptin levels and outcome might provide new insights when 
it comes to counselling parents experiencing an emotionally challenging period of their lives. 
 
Security of the collected data is given through data collection in especially signed folders (including case report 
forms) in the intensive care ward and through data storage in an especially signed electronic file (University 
Children`s Hospital Zurich). Data in the folders on the ward contain only data stored in clinical patient files 
anyway. Data will be managed strictly confidential, after initial data acquisition data will be coded through 
electronic storage with a study number and age (years + months, if <28 d in days); access to original data will only 
be given to the study personal and to institutions mentioned above. There will be no transfer of non-coded data to 
other storage systems outside the University Children`s Hospital Zurich. 
 
4. OBJECTIVES, ENPOINTS/OUTCOMES AND OTHER STUDY VARIABLES 
4.1 Objectives  
Primary objective 
The primary objective is to investigate the average change of blood copeptin levels in critically ill children and 
neonates with both arterial normo- and hypotension over 48h after intensive care unit (ICU) admission, and in a 
second step to describe the natural course and variability of copeptin levels over a period of up to 7 days after ICU 
admission. In this scope we will also investigate the association of patient characteristics (covariates) with blood 
copeptin baseline levels at ICU admission and the course of blood copeptin levels during ICU stay. In particular 
the association with the following factors will be investigated: 
• 
Arterial blood pressure (in particular hypotension vs. normotension), to identify patients that may most 
benefit from exogenous AVP treatment 
• 
Septic shock 
• 
Heart failure 
• 
Traumatic head injury, brain tumor and/or intracranial operation 
• 
Perinatal asphyxia 
• 
Severity of disease (disease score) 
• 
Age 
 
Secondary objective 
The secondary objective is to explore the association of individual copeptin levels over up to 7 days with the 
following clinical outcomes: 
a. 
Length of stay on the intensive care unit 
b. Length of respiratory support 
c. 
Length and dose of catecholamine therapy (as a marker of severity of disease and degree of arterial 
hypotension) 
d. Rate of death at day 28, 
and to explore the temporal and dynamic relationship between the course of blood pressure, blood copeptin levels 
and catecholamine therapy over time.  
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 14 of 27 

 
 
4.2 Primary and secondary endpoint/outcome(s) 
The primary endpoint of this study is descriptive, since the primary objective is simply to better understand which 
paediatric patients admitted to the ICU are likely to present with arterial hypotension in the presence of low 
copeptin levels over an observation period of up to 7 days. Results are expected to allow defining a group of 
patients that may benefit the most from exogenous AVP therapy. The effectiveness of exogenous AVP 
administration to patients with low AVP would have to be tested in a follow-up interventional trial. The patients 
participating in this present observational study will not receive any study medicaments. 
 
Definition and measurement of variables relevant to primary endpoint: 
Copeptin levels 
Blood copeptin values measured by the B·R·A·H·M·S Copeptin KRYPTOR (Thermo Fisher Scientific, 
Hennigsdorf, Germany) in all critical ill children and neonates admitted to the intensive care unit (ICU) will be 
analysed. Time points for blood sampling will be at ICU admission and then determined by other medical 
indications but scheduled to be performed with approximately 12, 24, and 48. Time points for all patients staying 
longer than 48 hours will be 96 and 168 hours to capture the presumed copeptin pattern in children. For the 
endogenous active hormone AVP it could be shown by Lee et al. in 2013 that AVP stays elevated for 120 hours/5 
days after onset of shock, but actual duration of AVP/copeptin elevation is unknown in children. Therefore, a last 
measurement with seven days will be included to show a potential decline of copeptin after the resolution of 
shock28. 
 
Arterial blood pressure and hypotension 
Hypotension is defined as systolic arterial pressure below age specific 5th percentiles according to reference values 
established in the context of the last International Pediatric Sepsis Consensus Conference (published 2005): 
newborn 0 days to 1 week 59 mmHg, neonate 1 week to 1 month 79 mmHg, infant 1 month to 1 year 75 mmHg, 
toddlers and preschool children 1 to 5 years 74 mmHg, school age children 5 to 12 years 83 mmHg, adolescent 
and young adult 12 to 18 years 90 mmHg49. Blood pressure will be measured invasively via indwelling central or 
peripheral arterial catheters or non-invasively via auscultatory or oscillometric techniques. 
 
Septic shock 
For the definition of “septic shock” sepsis, systemic inflammatory reaction (SIRS), and septic shock have to be 
defined50. 
Sepsis will be defined as systemic inflammatory reaction (SIRS) in the presence of suspected or proven infection.  
SIRS will be defined as the presence of at least two of the following four criteria, one of which must be abnormal 
temperature or leukocyte count: 1) Core temperature of >38.5°C or <36°C. 2) Tachycardia, defined as a mean 
heart rate >2 SD above normal for age in the absence of external stimulus, chronic drugs, or painful stimuli; or 
otherwise unexplained persistent elevation over a 0.5- to 4-hr time period OR for children <1 year old: bradycardia, 
defined as a mean heart rate <5th percentile for age in the absence of external vagal stimulus, beta-blocking drugs, 
or congenital heart disease; or otherwise unexplained persistent depression over a 0.5-hr time period. 3) Mean 
respiratory rate >2 SD above normal for age or mechanical ventilation for an acute process not related to underlying 
neuromuscular disease or the receipt of general anaesthesia. 4) Leukocyte count elevated or depressed for age (not 
secondary to chemotherapy-induced leukopenia) or >10% immature neutrophils. For all reference values see Table 
1). 
 
TABLE 1 
Age Group 
Heart Rate 
Tachycardia 
Beats/min 
Heart Rate 
Bradycardia 
Beats/min 
Respiratory Rate 
Breaths/Min 
 
Leukocyte 
Count 
103/mm3 
 
Systolic 
Blood 
Pressure 
mmHG 
0 days to 1 wk. 
>180 
<100 
<50 
>34 
<59 
1 wk. to 1 mo. 
>180 
<100 
<40 
>19.5 or <5 
<79 
1 mo. to 1 yr. 
>180 
<90 
<34 
>17.5 or <5 
<75 
2-5 yrs. 
>140 
NA 
<22 
>15.5 or <6 
<74 
6-12 yrs. 
>130 
NA 
<18 
>13.5 or <4.5 
<83 
13 to <18 yrs. 
>110 
NA 
<14 
>11 or <4.5 
<90 
Age-specific vital signs and laboratory variables (5th percentile for lower values for heart rate, leukocyte count,  
and systolic blood pressure and  95th percentile for upper values for heart rate, respiration rate, or leukocyte count)49,50 
 
Infection may be suspected or proven. Infection may be suspected by a clinical syndrome associated with a high 
probability of infection. Evidence of infection includes positive findings on clinical exam, imaging, or laboratory 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 15 of 27 

 
tests (e.g. white blood cells in a normally sterile body fluid, perforated viscus, and chest radiograph consistent with 
pneumonia, petechial or purpuric rash, or purpura fulminans). Infection will be defined as proven by positive 
culture, tissue stain, or polymerase chain reaction test and may be caused by any pathogen. 
Septic shock is defined as sepsis AND cardiovascular organ dysfunction (“Organ dysfunction criteria”, section on 
cardiovascular dysfunction later this chapter). 
 
Heart failure 
All patients with structural or functional impairment of heart function, leading to an inadequate amount of blood 
being pumped through the body, will be analysed as subgroup. Type of cardiopathy, cardiac lesions, preoperative 
medication, echocardiographic and cardiac catheter results, periods of cardiopulmonary bypass, cross clamping, 
deep hypothermic arrest, modified ultrafiltration, anaesthetics used, type of surgery, and the postoperative 
echocardiographic and laboratory results will be recorded for each patient. Patients will be defined as having 
preoperative congestive heart failure if they are treated with digoxin, diuretics, inhibitors of angiotensin converting 
enzyme, beta-blockers, or milrinone, or if they have congestive cardiac failure listed as diagnosis. 
 
Traumatic head injury, brain tumour and brain operation 
All children and adolescents with traumatic head injury, brain tumour and/or brain operation will be analysed as 
subgroup. Glasgow coma scale on admission and post resuscitation, presence and history of seizures, CT 
abnormalities as abnormal cisterns, midline shift >5mm, traumatic subarachnoidal haemorrhage, performance and 
type of intracranial surgery will be noted for each patient. In addition, intracranial pressure values and cerebral 
perfusion pressures will be recorded at each visit. 
 
Perinatal asphyxia 
Perinatal asphyxia causes neonatal encephalopathy. This is a clinically defined syndrome of disturbed neurologic 
function in the earliest days of life in an infant born at or beyond 35 weeks of gestation, manifested by a subnormal 
level of consciousness or seizures, and often accompanied by difficulty with initiating and maintaining respiration 
and depression of tone and reflexes. To assess children with neonatal asphyxia and consecutive encephalopathy, 
the following neonatal signs consistent with an acute peripartum or intrapartum hypoxic event must be met for 
study subgroup inclusion: Gestational age ≥35 weeks AND an Apgar score of <5 at 5 minutes and 10 minutes 
AND a foetal umbilical artery acidaemia: foetal umbilical artery pH <7.15, and/or base deficit ≥12 mmol/L AND 
presence of multisystem organ failure consistent with hypoxic-ischemic encephalopathy (two or more 
dysfunctional organ systems mentioned in section “Organ dysfunction criteria”)51. One important point defining 
hypoxic-ischemic encephalopathy is neuroimaging evidence of acute brain injury seen on brain magnet resonance 
imaging (MRI) consistent with hypoxia-ischemia (i.e. deep nuclear grey matter (basal ganglia or thalamus) and/or 
watershed cortical injury). As this imaging is usually performed after 96 hours of patient cooling in moderate and 
severe cases, it cannot be mandatory for study inclusion, but if available will be part of endpoint analysis. 
For endpoint assessment, the following will be noted: gestational age, Apgar-score, arterial umbilical cord pH, 
blood gas analysis, lactate, presence of arterial hypotension as defined as mean arterial pressure below the 
gestational age limit treated with intravenous corticosteroids, fluids and/or catecholamines, results of neurological 
imaging (cranial ultrasound and/or MRI), and performance of neonatal cooling as prevention of neurological 
damage.  
 
Organ dysfunction criteria: 
Cardiovascular dysfunction 
Despite administration of isotonic intravenous fluid bolus ≥40 mL/kg in 1 hr: 
• 
Decrease in BP (hypotension) <5th percentile for age or systolic BP <2 SD below normal for age 
OR 
• 
Need for vasoactive drug to maintain BP in normal range (dopamine, dobutamine, epinephrine, 
norepinephrine or vasopressin at any dose) 
OR 
• 
Two of the following: 
Unexplained metabolic acidosis: base deficit >5.0 mmol/L 
Increased arterial lactate >2 times upper limit of normal (2.0 mmol/L) 
Oliguria: urine output <0.5 mL/kg/hr 
Prolonged capillary refill: >5 s 
Core to peripheral temperature gap >3°C 
 
Respiratory dysfunction 
• 
PaO2/FIO2 <40 kPa in absence of cyanotic heart disease or pre-existing lung disease (i.e. acute respiratory 
distress syndrome (ARDS)) and acute lung injury (ALI). ARDS must include a PaO2/FIO2 ratio ≤26.6 kPa, 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 16 of 27 

 
bilateral infiltrates, acute onset, and no evidence of left heart failure. ALI is defined identically except the 
PaO2/FIO2 ratio must be ≤40 kPa. 
OR 
• 
PaCO2 >2.6 kPa over baseline PaCO2 
OR 
• 
Proven need (assumes oxygen requirement was tested by decreasing flow with subsequent increase in flow 
if required) or >50% FIO2 to maintain saturation ≥92% 
OR 
• 
Need for nonselective invasive or non-invasive mechanical ventilation (postoperatively, this requirement 
can be met if the patient has developed an acute inflammatory or infectious process in the lungs that 
prevents him or her from being extubated) 
 
Neurologic dysfunction 
• 
Glasgow Coma Score ≤11 
OR 
• 
Acute change in mental status with a decrease in Glasgow Coma Score ≥3 points from abnormal baseline 
 
Hematologic dysfunction 
• 
Platelet count <80,000/mm3 or a decline of 50% in platelet count from highest value recorded over the past 
3 days (for chronic haematology/oncology patients) 
OR 
• 
International normalized ratio >2 
 
Renal dysfunction 
• 
Serum creatinine ≥2 times upper limit of normal for age or 2-fold increase in baseline creatinine 
• 
Reference values: newborn 27 to 88 µmol/L; infant 18 to 35 µmol/L; child 27 to 62 µmol/L; adolescent 44 
to 88 µmol/L52 
 
Hepatic dysfunction 
• 
Total bilirubin ≥4 mg/dL (not applicable for newborn) 
OR 
• 
Alanine transaminase (ALT) 2 times upper limit of normal for age 
• 
Reference values (95th percentile): newborn – 18 month male: 60 U/L, female 55 U/L;18 month – 5 years 
male 40 U/L, female 35 U/L53; 5 – 8 years male 35 U/L, female 35; 9 – 13 years 44 U/L, female 35 U/L; 13 
- 18 years male 69 U/L; female 35 U/L54 
 
Severity of disease: 
Only one of the following disease scores will be evaluated per patient as appropriate for the respective age group 
 
• 
Paediatric Index of Mortality 255 (PIM 2): results in “predicted mortality risk” (range: 0-100%), calculated 
from available patient data at admission 
• 
Simplified Acute Physiology Score56 (SAPS II): results in an integer point score between 0 and 163 and a 
predicted mortality between 0% and 100%, calculated from 12 routine physiological measurements 
collected during first 24h after ICU admission (age, heart rate, systolic blood pressure) 
• 
Clinical Risk Index for Babies57 (CRIB II) : results in a score ranging from 0 to 27 and mortality probability 
ranging from 0-100%, calculated at admission from five variables (sex, birth weight, gestational age, 
temperature, base excess). 
 
Age: 
• 
Patients` age will be noted on study entrance. 
 
Definition and measurement of variables relevant to secondary endpoints: 
a) Length of ICU stay will be noted in hours. 
b) Length of respiratory support will be noted in hours, stratified by invasive and non-invasive ventilatory support. 
c) Length of catecholamine therapy will be noted in hours separately for every drug. In addition, the inotropic 
score for the estimation of amount of vasopressors used will be calculated with the equation by Wernovsky 
modified by Choong et al.: 1 point will be given for every µg/kg/min dopamine or dobutamine, 10 points will be 
given for every µg/kg/min milrinone and 100 points will be given for every µg/kg/min adrenaline or 
noradrenaline40,58. 
e) Death will be noted, rate of death at 28 days will be correlated with blood copeptin level. 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 17 of 27 

 
4.3 Other study variables 
The following endpoints will be noted, as copeptin results may differ when stratified according to: 
• 
Weight 
• 
Sex 
• 
Postnatal days and postconceptional age in neonates 
• 
Exogenous vasopressin administration 
5. PROJECT DESIGN  
5.1 Type of research and general project design  
The proposed study is designed as a single-centre prospective observational study.  
 
This design was chosen to gather data on all or at least on a large fraction of critically ill children and neonates 
admitted to our intensive care unit, assuming patients` or care takers informed consent. Further, as data on copeptin 
in critical ill children is scarce, no randomization or intervention other than taking blood samples will be necessary. 
Limitation: The observational study design will not be able to answer any kind of causative questions related to 
study findings. 
5.2 Procedures 
As soon as written informed consent is obtained from care takers, the study period will begin for the included 
children and neonates. The primary study period is defined as 48 hours. For all patients discharged from the ICU 
within 48 hours after admission, the study period will end with discharge from ICU. 62.3 % of patients stay less 
than 48h in the ICU of the University Children`s Hospital Zurich (median (10th- 90th percentile): 1.3 (0.4-9.2) 
days). The sample size was calculated to compensate for these patients discharged early. Patients staying longer 
than 48 hours (37.7%) are generally those patients with a higher degree of disease severity and are of specific 
interest. For all patients staying longer than 48 hours, the study period will end with discharge from ICU or with 
168 hours, whichever comes first,  
On admission demographic baseline data will be recorded on paper bedside case report forms as outlined in 
“Schedule of assessment (Flow of research project)” (i.e. age (years + months; if <28 days: postnatal days and 
postconceptional age), Apgar-score, arterial umbilical cord pH; diagnosis; disease-severity-scores; operation, 
preoperative parameters; weight; sex). Blood samples (600 µl) will be taken from all study patients on specific 
points of time (on admission, with 12, 24, 48, and, if still in ICU with 96, and 168 hours following admission), 
processed and stored at -80 °C for batch analyses later. Just before or after blood sampling the following clinical 
data will be recorded: arterial blood pressure; vital parameters (respiratory rate, peripheral oxygen saturation, 
arterial oxygen saturation, perfusion index, heart rate, peripheral pulses, capillary refill, urine output); laboratory 
values (sodium, potassium, calcium, chloride, troponin, creatine kinase, creatine kinase MB, pH, partial arterial 
oxygen pressure (PaO2), partial carbon arterial carbon dioxide pressure (PaCO2), base deficit, arterial lactate, 
glucose, alanine transaminase (ALT), creatinine, C-reactive protein, haemoglobin, white blood cell count, total 
bilirubin); neurological parameters (Glasgow Coma Scale, CT-findings (abnormal cisterns, midline shift >5mm, 
traumatic subarachnoidal haemorrhage, seizures, intracranial and cerebral perfusion pressure (if invasively 
monitored)); neonatal parameters (results of neonatal neurological imaging (cranial ultrasound and/or MRI) and 
performance of neonatal cooling as prevention of neurological damage). Importantly, laboratory parameters will 
only be assessed, if their analysis is otherwise medically indicated for limitation of blood loss and phlebotomy. As 
most critically ill patients have to be equipped with invasive hemodynamic monitoring allowing repetitive blood 
withdrawal, no additional phlebotomy should be necessary. Copeptin values will only be analysed, when the study 
blood sample can be taken alongside with other medically indicated blood samples. 
If the study patient is discharged from the ICU, the study period ends and no further blood samples or clinical data 
will be taken or analysed. Length of ICU stay will be noted. Every patient will be followed by study investigators 
for a total of 28 days to note date of discharge from ICU, Hospital and date of death, if applicable. 
As outlined in 2.4 “Participant Information and Informed Consent” this study may include patients, who 
themselves or whose caretakers may not be able to give written informed consent in emergency situations due to 
acute clinical deterioration, resuscitation and/or sedation of the patients. Further, care takers may not be present or 
accountable for formal medical explanations and may not be able to give informed consent at the time of intensive 
care unit admission due to the deterioration of their child.  
In this case, blood samples for copeptin will be taken, but not analysed. As soon as possible, but latest 24 hours 
following intensive care unit admission, written informed consent will be obtained. If no informed consent can be 
obtained within 24 h after ICU-admission, all blood samples will be destroyed and the patient will be excluded. 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 18 of 27 

 
5.3 Recruitment and Screening 
All care takers of eligible critically ill children or neonates admitted to the intensive care unit of the University`s 
Children Hospital Zurich will be consecutively assessed during daily clinical routine by study investigators. One 
hundred and seventy study patients are targeted and should be enrolled within 18 months, as a total of 1800 children 
and adolescents are admitted to the department of Intensive Care Medicine and Neonatology at the University`s 
Children Hospital Zurich. 
5.4 Methods of minimising bias  
This is an observational study comparing blood values to clinical conditions. As blood values have to be obtained 
via one of the procedures most routinely used in the intensive care setting (i.e. venous, arterial or capillary blood 
sampling), no relevant bias is expected to influence this point. All clinical parameters will be available open-label 
to treating physicians and study personal in medical charts, no bias is expected here either. Treating physicians 
will be blinded to copeptin values. Staff analysing copeptin levels at the BRAHMS laboratory will be blinded to 
clinical course of the patient.  
Taken together, no special bias entry points are relevant to this study. 
6. PROJECT POPULATION  
6.1 Inclusion criteria  
This is a study designed to explore Copeptin values in all kinds of critically ill paediatric patients. Patients with 
normal blood pressures will allow calculating Copeptin reference values for the ones requiring cardiovascular 
support. Therefore, all patients, irrespective of their medical condition (e.g. medical or surgical, mildly or 
severely affected) and their age (neonates to adolescents) admitted to the Intensive Care Unit of the University`s 
Children Hospital Zurich will be eligible, as long as they fulfil the following conditions: 
• 
Age: first day of life until 18th birthday. 
• 
Ability of the care taker or the adolescent (if≥14 years of age) to understand verbal and written instructions 
and informed consent in German. 
 
6.2 Exclusion criteria  
Patients will not be included in the study for the following reasons: 
• Care taker or adolescent (if ≥14 years of age) unwilling to give written informed consent. 
• Care taker or adolescent (if ≥14 years of age) not understanding German and without a family member able 
to translate. 
• Adolescent (if ≥14 years of age) unwilling to give written informed consent following sedation < 24 hours. 
• Care takers of long-term sedated (>24 hours) adolescents (if ≥14 years of age) unwilling to give written 
informed consent or not present within 24 hours. 
6.3 Criteria for withdrawal / discontinuation of participants  
For the following reasons the study period will end immediately for the included patients. 
• Withdrawal of informed consent 
• Discharge from Intensive Care Unit 
• Death 
7. PROJECT ASSESSMENTS  
7.1 Project flow chart(s) / table of procedures and assessments 
Please see study flow chart under “SCHEDULE OF ASSESSMENTS (FLOW OF RESEARCH PROJECT)”, 
page 8. 
7.2 Assessments of primary endpoint/outcome  
The following primary endpoint variable will be obtained in laboratory analysis and stored in an electronic 
database: 
• 
Blood copeptin values. All study blood samples will be send labelled with patients` names and study 
numbers to the internal laboratory of the University Children`s Hospital Zurich for centrifugation, aliquot 
preparation and storage. The stored aliquots assigned to copeptin analysis will be sent in batches to 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 19 of 27 

 
BRAHMS (Thermo Fisher Scientific) in Hennigsdorf, Germany. Before the aliquots leave the Children`s 
Hospital Zurich, all aliquots will be re-labelled manually by study staff to be coded with study number 
only. All results will be received from BRAHMS in a coded form and stored in a coded database inside 
the University Children`s Hospital Zurich. 
The following primary endpoint variables will be obtained and noted on bedside paper case report forms: 
• 
Arterial blood pressure: obtained via invasive (indwelling peripheral or central arterial catheters) or non-
invasive (oscillometric or auscultatory) measurements. 
• 
Diagnosis. 
• 
Vital parameters: respiratory rate, peripheral oxygen saturation, arterial oxygen saturation, perfusion 
index, heart rate, peripheral pulses, capillary refill, urine output. 
• 
Laboratory values: sodium, potassium, calcium, chloride, troponin, creatine kinase, creatine kinase MB, 
pH, partial arterial oxygen pressure (PaO2), partial carbon arterial carbon dioxide pressure (PaCO2), base 
deficit, arterial lactate, glucose, alanine transaminase (ALT), creatinine, C-reactive protein, haemoglobin, 
white blood cell count, total bilirubin; all if medically indicated. 
• 
Fluid administration/24h each day. 
• 
Operation and perioperative parameters, i.e. preoperative medication, anaesthetics, type of surgery; if 
cardiac surgery in addition: cardiac lesion, echocardiographic and cardiac catheter results, periods of 
cardiopulmonary bypass, cross clamping, deep hypothermic arrest, modified ultrafiltration, postoperative 
echocardiographic results. 
• 
Neurological findings: Glasgow Coma Scale, CT-results (abnormal cisterns, midline shift >5mm, 
traumatic subarachnoidal haemorrhage, seizures, intracranial and cerebral perfusion pressure (if 
invasively monitored)). 
• 
Neonatal findings: Apgar-score, arterial umbilical cord pH, results of neurological imaging (cranial 
ultrasound and/or MRI), and performance of neonatal cooling as prevention of neurological damage. 
• 
Organ dysfunction/mechanical resuscitation. 
• 
Disease-Severity-Scores (PIM 2, SAPS II, CRIB II). 
 
7.3 Assessment of secondary endpoint/outcome(s) 
The following secondary endpoint variables will be obtained and noted on bedside paper case report forms at the 
scheduled time points of assessment and blood sampling: 
 
• 
Discharge date from ICU as determined by the moment of decision made by treating physicians for 
discharge, even though immediate discharge may not be possible due to capacity reasons of the targeted 
peripheral ward. 
• 
Respiratory support. 
• 
Vasoactive Drugs. 
• 
Serious (Adverse) Events/Death. 
7.4 Assessment of other study variables 
The following further study variables will be obtained and noted on bedside paper case report forms: 
• 
Weight 
• 
Sex 
• 
Age in years and months. If neonatal (<28 d): postnatal days + postconceptional age  
• 
Other drugs, exogenous vasopressin administration 
 
7.5 Assessment of safety and reporting 
7.5.1 
Definition of Serious Events (SEs) 
A serious event is any unfavourable event for which a causal relationship to sampling of biological material or 
the collection of health related personal data cannot be ruled out, and which: 
• 
requires hospitalisation or prolongation of an inpatients’ hospitalisation, 
• 
results in persistent or significant disability or incapacity, or 
• 
is life-threatening or results in death, 
If a serious event occurs the research project will be set on hold. 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 20 of 27 

 
7.5.2 
Assessment and Documentation of SEs 
The assessment by the project leader with regard to the project-specific measure relation is done according to the 
following definitions: 
• 
Unrelated: The occurrence of the event has no temporal relationship to the project-specific measures applied 
and can be explained by the underlying disease or other factors. 
• 
Related: There is a plausible temporal relationship between the occurrence of the event and the project-
specific, applied measures and cannot be explained by the underlying disease or other factors. 
 
All SEs are to be documented in the participants´ file and on the SE report form. A sample form is appended to 
the Protocol and can be downloaded at www.swissethics.com. 
 
7.5.3 
Reporting of SEs, Safety and Protective Measures 
The project leader shall report any occurring SE to the responsible EC within 7 days (and to the FOPH in case of 
involved radioactive sources). He/she shall also submit a report which evaluates the relationship between the 
event reported and the methods of collecting health related personal data or sampling of biological material 
within that project, furthermore proposals how to proceed with the project. 
The project leader will notify the EC within 7 days of any immediate other safety and protective measures, 
which have to be taken during the conduct of the research project. In addition, the project leader will explain the 
circumstances, which necessitated the safety and protective measures.  
8. STATISTICAL METHODOLOGY  
8.1 Determination of Sample Size  
 
The sample size calculation is based on the primary objective, namely to investigate the average change of blood 
copeptin levels (mean difference between time-points, i.e. from admission to 12h, from 12h to 24h, from 24h to 
48h) in critically ill children and neonates with both arterial normo- and hypotension over 48h after ICU 
admission. 
 
Assumptions: 
1. We hypothesize that the mean difference in blood copeptin levels between two time-points is not 0 (as 
assessed by a two-sided t-test, assuming equal variance). 
2. We base corresponding sample size calculations on the data in the study from Lee et al. (2013)28 since 
this paper provides blood copeptin levels at different time points from patients with septic shock 
admitted to the PICU, i.e. a population similar to a part of the population expected in the present study:  
 
Table 2: Blood copeptin levels measured in the study of Lee et al. (2013). 
Time 
Healthy  
n=70 
 
Median (IQR) 
[ng/mL 
Copeptin] 
Sepsis 
n=53 
 
Median (IQR) 
[ng/mL 
Copeptin] 
Septic shock 
(PICU), n=13 
 
Median* (IQR) 
[ng/mL Copeptin] 
Difference in 
means between 
period 
 
[ng/mL] 
Interquartile 
range (IQR) 
 
[ng/mL]  
0-24 h 
12 (0.8-1.8)  
1.5 (1.0-2.2) 
0.9 (0.8-1.2) 
- 
0.4 
48 h 
 
 
1.2 (0.7-1.8) 
0.3  
1.1 
72 h 
 
 
1.25 (0.8-1.8) 
0.05 
1.0 
96 h 
 
 
1.5 (1.3-1.7) 
0.25 
0.4 
120 h 
 
 
2.0 (1.0-2.2) 
0.5 
1.2 
*we assume normal distribution and use the reported median as mean in the following, as discussed below. 
 
3. For the relevant time points the maximum mean difference between time points is d = 0.3 ng/mL (from 
0-24h to 48h, highlighted in blue in the Table 2 above), the interquartile range (IQR) is approximately 
1.1 ng/mL. 
4. We assume normality, which seems reasonable given the data only seem slightly skewed (median – 0.5, 
median +0.6). The IQR is then approximately 4/3 of a standard deviation (sd), i.e. sd = 0.75 x 1.1 
ng/mL = 0.82 ng/mL. 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 21 of 27 

 
5. For the power calculation, we fix the significance level at 5%, and vary the power to determine the 
effect on possible sample size (Table 3). We use the standard difference in means calculation (t-test). 
 
Table 3: Power calculation without adjustment for drop-out or other reasons of 
missing data. *effect = d/sd 
Power 
Sample size for effect* = 0.36 (0.5) 
0.8 
62 (26) 
0.9 
82 (37) 
0.95 
101 (45) 
 
6. The median PICU length of stay was 6 days, whereas internal data of Zurich’s PICU suggests an even 
shorter median length of stay (1.3 days, see below), with only 40% of patients staying at least 48h. We 
thus assume a 60% drop out before the end of the targeted observation period of 48 hours (see above), 
which means that we need to multiply our sample size by 10/4. 
7. We assume that at least 90% of the blood copeptin values are within the measurable range of the assay 
(0.02-4.8 ng/mL), which means that we need to multiply our sample size by 10/9 to account for an 
additional potential 10% of missing data. 
 
Conclusion: Assuming 80% power, 5% significance level a sample size of 62 x 2.5 x 1.1 = 170 patients with an 
effect size of 0.36 (mean difference d=0.3 ng/mL, sd=0.8 ng/mL, 60% drop out, 10% of data below lower limit 
of quantification) is needed for this study. 
 
8.2 Planned analysis 
8.2.1 
Datasets to be analysed 
Analysis population 
• 
The primary analysis population for the assessment of the mean difference in blood copeptin levels 
between time points within the first 48 hours after ICU admission is the full analysis set of all included 
patients (intention-to-treat analysis). Associations of copeptin levels with the following covariates will 
be analysed in all included patients: arterial blood pressure, severity of disease and age. Associations with 
further patient characteristics as septic shock, heart failure, traumatic brain injury, perinatal asphyxia will 
be analysed in affected patients only. 
• 
The secondary analyses (association of copeptin levels with clinical outcome) will be done in all patients 
for whom the respective information is available (see 8.2.2 Handling of Missing data). 
Analysis tool 
All relevant clinical and laboratory parameters obtained during the study period will be analysed using SPSS 22 
(IBM, Armonk, NY, USA), R (R Core Team, Vienna, Austria), and NONMEM (Icon Development Solutions, 
Ellicott City, MD, USA). 
 
Endpoint analysis 
Primary endpoint 
The mean difference in blood copeptin levels between time points (admission – 12h, 12h-24h, 24h-48h) will be 
analysed using a two-sided t-test. 
 
The course of individual blood copeptin levels over up to 7 days will be analysed using linear and non-linear 
mixed-effect regression modelling, which allows to characterize both the individual and overall typical (median) 
time course simultaneously, and to quantify associated inter-individual variability. The influence of/association 
with covariates (e.g. age, blood pressure, particular underlying diseases such as septic shock or heart failure) on 
both the baseline and the course of copeptin levels will be investigated in this scope (“copeptin kinetic model”). 
 
The final “copeptin kinetic” regression model will be used for stochastic (Monte-Carlo) simulations to determine 
the proportions of patients below a specific blood copeptin level (in particular >1.12 ng/mL, which has been 
suggested to indicate vasopressin insufficiency27) at any time point and to evaluate its discriminatory potential to 
identify patients with hypotension that may most benefit from exogenous AVP treatment. The model-predicted 
proportions will be evaluated by comparing them to the empirically calculated proportions of patients with blood 
copeptin levels < 1.12 ng/mL at each specifically measured time point with 95% confidence intervals. 
 
Secondary endpoints 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 22 of 27 

 
Finally, measured blood copeptin levels and/or model-derived individual parameters characterizing the course of 
individual blood copeptin levels will be investigated as predictor variables for length of ICU stay, length of 
respiratory support and survival in a time-to-event analysis, and for severity of disease (including dose of 
catecholamine therapy) in a regression analysis. 
 
In a more advanced analysis, also the time-course of blood pressure measurements will be analysed and 
characterized in a mixed-effect regression analysis. The temporal and dynamic relationship between blood 
copeptin and blood pressure will be furthermore assessed. 
8.2.2 
Handling of missing data 
Primary outcome: 
Missing blood copeptin and/or blood pressure data is expected to occur at time points after baseline assessment 
because of the following reasons: 
• 
Transfer to another unit (mainly associated with improvement of patient condition) 
• 
Death (associated with worsening of patient condition) 
 
Missing copeptin and/or blood pressure data may occur at any time point because of the following reasons: 
• 
Measurement below the limit of quantification of the analytical method (only copeptin) 
• 
Technical difficulties in blood sampling and/or blood pressure measurement 
• 
Consent withdrawal 
 
The remaining covariates, including age and medical condition (including septic shock, heart failure, traumatic 
head injury, brain tumor and/or intracranial operation, perinatal asphyxia and severity of disease) are unlikely to 
be missing since they are assessed at ICU admission and included in the electronic patient record.  
 
For the initial assessment of blood copeptin kinetics, all individual data independent of later missing blood 
copeptin measurements will be included in the analysis (“full analysis”, i.e. according to the intention-to-treat 
principle). One advantage of the planned mixed-effect modelling is that it can indeed handle unbalanced individual 
data. Measurements below the limit of quantification will not be omitted but included as censored measurements. 
Missing covariates at specific time points (age, blood pressure) will be imputed or interpolated based on other 
observed individual data (e.g. based on previous and/or subsequent assessments). 
In a sensitivity analysis, the time-course of only complete patient data over 7 days (“complete case analysis”, i.e. 
per protocol) will be compared with the “full analysis set” and model parameters will be assessed for a bias induced 
by potentially copeptin-dependent (i.e. non-random) missingness reasons.  
If a bias is suggested we will furthermore investigate the time-course of copeptin in patients with missing data, 
stratified for different reasons of missingness (“stratified sub-analyses”). 
 
Secondary outcome: 
Missing secondary outcomes (date of discharge from ICU, date of end of respiratory support, date of death) can 
occur because the observation period may not be long enough to observe these events. Therefore, these unobserved 
outcomes will be right-censored in the time-to-event analysis (i.e. censored at random).  
Catecholamine prescription is part of the electronic patient record. A non-reported dose of catecholamines will 
therefore be handled as such. 
8.2.3 
Ancillary analysis 
If sample serum volume permits measurement of additional biomarkers, the two following biomarkers would be 
measured none-mandatorily in decreasing priority: Procalcitonin to contribute to the creation of an international 
agreed-on threshold for procalcitonin-guided antibiotic treatment of intensive care patients; and MR-proADM to 
evaluate the so far in critically ill children little-explored predictive value for organ failure and mortality. Rests 
of serum samples may be used for future biomarkers unknown today. 
8.2.4 
Deviations from the original statistical plan 
There are no likely deviations from the research plan. All unforeseen deviations from the original research plan 
will be reported to the local ethics committee by the project leader. 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 23 of 27 

 
9. DATA AND QUALITY MANAGEMENT  
9.1 Data handling and record keeping / archiving  
Demographic baseline data, diagnosis, vital parameters, laboratory values, respiratory parameters, vasoactive and 
other drugs, fluids administered and neurological data are noted at the time of blood sampling on bedside case 
report forms. Copeptin values will be analysed later in complete batches at BRAHMS, Henningsdorf, Berlin. All 
blood samples will leave the University Children`s Hospital Zurich strictly coded by study number without patients 
names or date of birth. For analysis, coded electronic storage of all data including copeptin values with study 
number and age in years and months (if neonatal (<28 days) in days) in a SPSS database will be used. To allow 
tracking of database changes every day changes are made to the database a PDF copy of the SPSS database (SPPS-
>export to Microsoft Excel-> save as PDF) will be electronically stored in a password-protected electronic folder 
inside the University Children`s Hospital Zurich. The respective password is known only to V. Cannizzaro, MD, 
PhD and to P. Baumann, MD. The folder will be available to legal authorities, monitors and audits for review. 
 
9.2 Confidentiality, Data Protection  
All individual participant medical information obtained in this study is considered confidential and disclosure to 
third parties is prohibited. Data will be initially noted on bedside paper case report forms, which then will be stored 
in especially marked folders on the intensive care ward. All data transferred to the SPSS study data base will be 
stored inside the University Children`s Hospital Zurich. 
For data verification purposes, direct access to parts of the medical records relevant to the project, including 
participants’ medical history, will only be given to a competent authority or an ethics committee. 
As mentioned in 8.2.3 rests of serum samples may be used for procalcitonin and pro-ADM analyses as well as 
future biomarkers unknown today. The patients and their care takers have to give informed consent for this 
separately. If an adolescent ≥ 14 years of age is sedated or for other reasons not able to give informed consent, this 
has to be obtained for the use of serum samples rests in any case from her-/himself as soon as the adolescent is 
able to give consent. The legal care takers cannot give informed consent in place of the adolescent for the use of 
serum sample rests. 
 
9.3 Coding 
Except blood copeptin values all obtained medical information is open-label and used for clinical routine. 
Therefore no initial coding of primary data is necessary. When primary data are transferred to the SPSS database, 
data will be coded by study number and age in years and months (if neonatal (<28 days) in days). The blood 
samples will be sent to the laboratory of the University Children`s Hospital Zurich labelled with names and date 
of birth. The staff at the internal laboratory of the Children`s Hospital Zurich is not blinded to the names, but as 
this is daily routine in the laboratory, patients` data are protected by professional discretion as this applies also to 
all other patients of the University Children`s Hospital Zurich. Further, besides from pre-processing no analysis 
will be performed in the internal laboratory.  Before aliquots leave the University Children`s Hospital Zurich, they 
will be re-labelled by study staff with study number only. Only coded blood samples will leave the University 
Children`s Hospital Zurich.  
 
9.4 Archiving and Destruction 
Paper bedside case report forms contain only information of the medical file. Paper folders will be stored inside 
the University Children`s Hospital Zurich, room H-1.C13. Data will be electronically stored on hard drives inside 
the University Children`s Hospital Zurich.  
Blood samples will be stored inside the laboratories of the University Children`s Hospital Zurich at -80°C. Aliquots 
batches sent to BRAHMS in Germany will be entirely used for copeptin analyses. If further aliquots remain at the 
University Children`s Hospital Zurich, these will be stored for potential additional analyses later. 
10. PUBLICATION AND DISSEMINATION POLICY  
10.1 Publication of results 
Results will be presented on national and/or international conferences for discussion.  
Further, results will be published in a peer-reviewed medical journal. 
 
Criteria for authorship 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 24 of 27 

 
Each author should have participated sufficiently in the work to take public responsibility for the content. 
Authorship credit should be based on substantial contributions to 1) the intellectual content (i.e., conception and 
design, acquisition, analysis, and interpretation of data); and to 2) drafting of the article or revising it critically and 
prompt for important intellectual content; and 3) final approval of the version to be published. Potential conflicts 
of interest will be listed. Additional journal-specific regulations may apply. 
10.2 Data sharing 
No sharing planned. 
11. FUNDING AND SUPPORT  
This is an investigator-initiated trial. All personal costs will be covered by the University Children`s Hospital 
Zurich. P. Baumann, MD, clinical and research fellow on the Intensive Care Unit and Neonatology ward of the 
University Children`s Hospital Zurich, received an unrestricted research and educational grant from SenTec, 
Therwil, Switzerland for his clinical and scientific formation. Dr. Baumann is involved in various clinical and 
laboratory studies on the Intensive Care Unit of the University Children`s Hospital Zurich and this grant is not 
limited to one specific study. Statistician V. Gotta will do all calculations and work for the study without 
payment. Publication costs will be covered by the University Children`s Hospital Zurich. The University 
Children`s Hospital Zurich does not receive any kind of payment for the conduct of the study.  
All costs for shipment and analysis of copeptin values will be covered by Thermo Fisher Scientific, Hennigsdorf, 
Germany. To exclude any conflicts of interest, no commercial sponsor will have any involvement in design and 
conduct of the study, namely collection, management, analysis, and interpretation of the data; and preparation, 
decision to submit, review, or approval of the manuscript. Results will be published, irrespective, if they may be 
favourable or not for the manufacturer. The project leader and involved persons declare no conflict of interest.  
12. INSURANCE  
As this study places the included patients at only minimal risk (risk category A), no specific study insurance is 
necessary. Any kind of relevant harm to the patients related to the study is covered by the general liability insurance 
of the University Children`s Hospital. Costs for the insurance are covered by the University Children`s Hospital 
Zurich. 
13. REFERENCES  
1. 
Wolfler A, Silvani P, Musicco M, Antonelli M, Salvo I. Incidence of and mortality due to sepsis, severe 
sepsis and septic shock in Italian Pediatric Intensive Care Units: a prospective national survey. Intensive Care 
Med 2008; 34(9): 1690-7. 
2. 
Gupta RG, Hartigan SM, Kashiouris MG, Sessler CN, Bearman GM. Early goal-directed resuscitation of 
patients with septic shock: current evidence and future directions. Crit Care 2015; 19(1): 286. 
3. 
Wernovsky G, Kuijpers M, Van Rossem MC, et al. Postoperative course in the cardiac intensive care unit 
following the first stage of Norwood reconstruction. Cardiology in the Young 2007; 17(06): 652-65. 
4. 
Tweddell JS, Hoffman GM, Fedderly RT, et al. Patients at risk for low systemic oxygen delivery after the 
Norwood procedure. The Annals of Thoracic Surgery 2000; 69(6): 1893-9. 
5. 
Kissoon N, Orr RA, Carcillo JA. Updated American College of Critical Care Medicine--pediatric advanced 
life support guidelines for management of pediatric and neonatal septic shock: relevance to the emergency care 
clinician. Pediatr Emerg Care 2010; 26(11): 867-9. 
6. 
Killinger JS, Hsu DT, Schleien CL, Mosca RS, Hardart GE. Children undergoing heart transplant are at 
increased risk for postoperative vasodilatory shock*. Pediatr Crit Care Med 2009; 10(3): 335-40. 
7. 
Maitland K, Kiguli S, Opoka RO, et al. Mortality after Fluid Bolus in African Children with Severe 
Infection. N Engl J Med 2011; 364(26): 2483-95. 
8. 
Maniaci V, Dauber A, Weiss S, Nylen E, Becker KL, Bachur R. Procalcitonin in Young Febrile Infants for 
the Detection of Serious Bacterial Infections. Pediatrics 2008; 122(4): 701-10. 
9. 
Podrid PJ, Fuchs T, Candinas R. Role of the sympathetic nervous system in the genesis of ventricular 
arrhythmia. Circulation 1990; 82(2 Suppl): I103-13. 
10. 
Dünser MW, Mayr AJ, Ulmer H, et al. Arginine Vasopressin in Advanced Vasodilatory Shock: A 
Prospective, Randomized, Controlled Study. Circulation 2003; 107(18): 2313-9. 
11. 
Cheung PY, Barrington KJ, Pearson RJ, Bigam DL, Finer NN, Van Aerde JE. Systemic, pulmonary and 
mesenteric perfusion and oxygenation effects of dopamine and epinephrine. Am J Respir Crit Care Med 1997; 
155(1): 32-7. 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 25 of 27 

 
12. 
Gedeborg R, Silander HC, Ronne-Engstrom E, Rubertsson S, Wiklund L. Adverse effects of high-dose 
epinephrine on cerebral blood flow during experimental cardiopulmonary resuscitation. Crit Care Med 2000; 
28(5): 1423-30. 
13. 
Alten JA, Borasino S, Toms R, Law MA, Moellinger A, Dabal RJ. Early initiation of arginine vasopressin 
infusion in neonates after complex cardiac surgery*. Pediatr Crit Care Med 2012; 13(3): 300-4. 
14. 
Burton GL, Kaufman J, Goot BH, da Cruz EM. The use of Arginine Vasopressin in neonates following 
the Norwood procedure. Cardiology in the Young 2011; 21(05): 536-44. 
15. 
Lechner E, Hofer A, Mair R, Moosbauer W, Sames-Dolzer E, Tulzer G. Arginine-vasopressin in neonates 
with vasodilatory shock after cardiopulmonary bypass. European Journal of Pediatrics 2007; 166(12): 1221-7. 
16. 
Jerath N, Frndova H, McCrindle B, Gurofsky R, Humpl T. Clinical impact of vasopressin infusion on 
hemodynamics, liver and renal function in pediatric patients. Intensive Care Med 2008; 34(7): 1274-80. 
17. 
Morrison WE, Simone S, Conway D, Tumulty J, Johnson C, Cardarelli M. Levels of vasopressin in 
children undergoing cardiopulmonary bypass. Cardiology in the Young 2008; 18(02): 135-40. 
18. 
Mastropietro CW, Davalos MC, Seshadri S, Walters HLI, Delius RE. Clinical response to arginine 
vasopressin therapy after paediatric cardiac surgery. Cardiology in the Young 2013; 23(03): 387-93. 
19. 
Rosenzweig EB, Starc TJ, Chen JM, et al. Intravenous Arginine-Vasopressin in Children With 
Vasodilatory Shock After Cardiac Surgery. Circulation 1999; 100(suppl 2): II-182-Ii-6. 
20. 
Mastropietro CW, Clark JA, Delius RE, Walters HLI, Sarnaik AP. Arginine vasopressin to manage 
hypoxemic infants after stage I palliation of single ventricle lesions. Pediatr Crit Care Med 2008; 9(5): 506-10. 
21. 
Zingg HH. Vasopressin and oxytocin receptors. Baillière's Clinical Endocrinology and Metabolism 1996; 
10(1): 75-96. 
22. 
Thibonnier M. Signal transduction of V1-vascular vasopressin receptors. Regulatory Peptides 1992; 
38(1): 1-11. 
23. 
Serpa Neto A, Nassar A, Cardoso S, et al. Vasopressin and terlipressin in adult vasodilatory shock: a 
systematic review and meta-analysis of nine randomized controlled trials. Critical Care 2012; 16(4): R154. 
24. 
Matok I, Rubinshtein M, Levy A, et al. Terlipressin for Children with Extremely Low Cardiac Output After 
Open Heart Surgery. Annals of Pharmacotherapy 2009; 43(3): 423-9. 
25. 
Rios DR, Kaiser JR. Vasopressin versus Dopamine for Treatment of Hypotension in Extremely Low Birth 
Weight Infants: A Randomized, Blinded Pilot Study. The Journal of Pediatrics 2015; 166(4): 850-5. 
26. 
Rios DR, Moffett BS, Kaiser JR. Trends in Pharmacotherapy for Neonatal Hypotension. The Journal of 
Pediatrics 2014; 165(4): 697-701.e1. 
27. 
Mastropietro C, Mahan M, Valentine K, et al. Copeptin as a marker of relative arginine vasopressin 
deficiency after pediatric cardiac surgery. Intensive Care Med 2012; 38(12): 2047-54. 
28. 
Lee J, Chan Y, Lai O, Puthucheary J. Vasopressin and copeptin levels in children with sepsis and septic 
shock. Intensive Care Med 2013; 39(4): 747-53. 
29. 
Lodha R, Vivekanandhan S, Sarthi M, Kabra SK. Serial circulating vasopressin levels in children with 
septic shock*. Pediatr Crit Care Med 2006; 7(3): 220-4. 
30. 
Mastropietro CW, Rossi NF, Clark JA, et al. Relative deficiency of arginine vasopressin in children after 
cardiopulmonary bypass*. Crit Care Med 2010; 38(10): 2052-8. 
31. 
Landry DW, Levin HR, Gallant EM, et al. Vasopressin Deficiency Contributes to the Vasodilation of 
Septic Shock. Circulation 1997; 95(5): 1122-5. 
32. 
Sharshar T, Blanchard A, Paillard M, Raphael JC, Gajdos P, Annane D. Circulating vasopressin levels in 
septic shock. Crit Care Med 2003; 31(6): 1752-8. 
33. 
Baumann G, Dingman JF. Distribution, blood transport, and degradation of antidiuretic hormone in man. 
The Journal of Clinical Investigation 1976; 57(5): 1109-16. 
34. 
Robertson GL, Mahr EA, Athar S, Sinha T. Development and Clinical Application of a New Method for 
the Radioimmunoassay of Arginine Vasopressin in Human Plasma. The Journal of Clinical Investigation 1973; 
52(9): 2340-52. 
35. 
Preibisz JJ, Sealey JE, Laragh JH, Cody RJ, Weksler BB. Plasma and platelet vasopressin in essential 
hypertension and congestive heart failure. Hypertension 1983; 5(2 Pt 2): I129-38. 
36. 
Morgenthaler NG, Struck J, Alonso C, Bergmann A. Assay for the Measurement of Copeptin, a Stable 
Peptide Derived from the Precursor of Vasopressin. Clinical Chemistry 2006; 52(1): 112-9. 
37. 
Jochberger S, Morgenthaler NG, Mayr VD, et al. Copeptin and Arginine Vasopressin Concentrations in 
Critically Ill Patients. The Journal of Clinical Endocrinology & Metabolism 2006; 91(11): 4381-6. 
38. 
Jochberger S, Velik-Salchner C, Mayr V, et al. The vasopressin and copeptin response in patients with 
vasodilatory shock after cardiac surgery: a prospective, controlled study. Intensive Care Med 2009; 35(3): 489-97. 
39. 
Westermann I, Dünser MW, Haas T, et al. ENDOGENOUS VASOPRESSIN AND COPEPTIN 
RESPONSE IN MULTIPLE TRAUMA PATIENTS. Shock 2007; 28(6): 644-9. 
40. 
Choong K, Bohn D, Fraser DD, et al. Vasopressin in pediatric vasodilatory shock: a multicenter 
randomized controlled trial. Am J Respir Crit Care Med 2009; 180(7): 632-9. 
41. 
Schlapbach LJ, Frey S, Bigler S, et al. Copeptin concentration in cord blood in infants with early-onset 
sepsis, chorioamnionitis and perinatal asphyxia. BMC Pediatr 2011; 11: 38. 
42. 
L’Abate P, Wiegert S, Struck J, Wellmann S, Cannizzaro V. Determinants of plasma copeptin: A 
systematic investigation in a pediatric mechanical ventilation model. Respiratory Physiology & Neurobiology 2013; 
185(2): 222-7. 
43. 
Du J-M, Sang G, Jiang C-M, He X-J, Han Y. Relationship between plasma copeptin levels and 
complications of community-acquired pneumonia in preschool children. Peptides 2013; 45: 61-5. 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 26 of 27 

 
44. 
Lin C, Wang N, Shen Z-P, Zhao Z-Y. Plasma copeptin concentration and outcome after pediatric 
traumatic brain injury. Peptides 2013; 42: 43-7. 
45. 
Lipinski MJ, Escárcega RO, D'Ascenzo F, et al. A Systematic Review and Collaborative Meta-Analysis to 
Determine the Incremental Value of Copeptin for Rapid Rule-Out of Acute Myocardial Infarction. The American 
Journal of Cardiology 2014; 113(9): 1581-91. 
46. 
Choi K-S, Kim HJ, Chun H-J, et al. Prognostic role of copeptin after stroke: A systematic review and 
meta-analysis of observational studies. Scientific Reports 2015; 5: 11665. 
47. 
Ristagno G, Latini R, Plebani M, et al. Copeptin levels are associated with organ dysfunction and death 
in the intensive care unit after out-of-hospital cardiac arrest. Critical Care 2015; 19(1): 132. 
48. 
Schrimpf C, Gillmann H-J, Sahlmann B, et al. Renal Function Interferes with Copeptin in Prediction of 
Major Adverse Cardiac Events in Patients Undergoing Vascular Surgery. PLoS ONE 2015; 10(4): e0123093. 
49. 
Goldstein B, Giroir B, Randolph A. Reply: Values for Systolic Blood Pressure. Pediatr Crit Care Med 
2005; 6(4): 500-1. 
50. 
Goldstein B, Giroir B, Randolph A, Sepsis MotICCoP. International pediatric sepsis consensus 
conference: Definitions for sepsis and organ dysfunction in pediatrics*. Pediatr Crit Care Med 2005; 6(1): 2-8. 
51. 
Gynecologists ACoOa. Executive Summary: Neonatal Encephalopathy and Neurologic Outcome, 
Second Edition. Obstetrics & Gynecology 2014; 123(4): 896-901. 
52. 
The Harriet Lane Handbook. In: Tschudy K, Arcara K, eds. 19th ed. St. Louis: Mosby; 2012: 642. 
53. 
England K, Thorne C, Pembrey L, Tovo P-A, Newell M-L. Age- and Sex-related Reference Ranges of 
Alanine Aminotransferase Levels in Children: European Paediatric HCV Network. Journal of Pediatric 
Gastroenterology and Nutrition 2009; 49(1): 71-7. 
54. 
Hilsted L, Rustad P, Aksglæde L, Sørensen K, Juul A. Recommended Nordic paediatric reference 
intervals for 21 common biochemical properties. Scandinavian Journal of Clinical and Laboratory Investigation 
2013; 73(1): 1-9. 
55. 
Slater A, Shann F, Pearson G. PIM2: a revised version of the Paediatric Index of Mortality. Intensive 
Care Med 2003; 29(2): 278-85. 
56. 
Le Gall J, Lemeshow S, Saulnier F. A new simplified acute physiology score (saps ii) based on a 
european/north american multicenter study. JAMA 1993; 270(24): 2957-63. 
57. 
Parry G, Tucker J, Tarnow-Mordi W. CRIB II: an update of the clinical risk index for babies score. The 
Lancet 2003; 361(9371): 1789-91. 
58. 
Wernovsky G, Wypij D, Jonas RA, et al. Postoperative Course and Hemodynamic Profile After the 
Arterial Switch Operation in Neonates and Infants: A Comparison of Low-Flow Cardiopulmonary Bypass and 
Circulatory Arrest. Circulation 1995; 92(8): 2226-35. 
 
 
COpeptin in critically ill Paediatric and Neonatal Intensive Care patients 
and its association with arterial hypotension – The COPNIC-Study 
Version 2.2 (17/08/2017) 
 
page 27 of 27