HaemoAdsorption Nach Reanimation An ECMO
Phase: NA
Conditions: Cardiac Arrest, Resuscitation, Inflammation, Multi-Organ Disorder
Sponsor: Universitätsklinikum Hamburg-Eppendorf

Hamburg, 29th December 2017
Study protocoll of the prospective Study
Version 1.2
HaemoAdsorption Nach Reanimation An ECMO (HANRAE) 
Prof. Dr. med. Jens Kubitz, MD, PhD
and
Eike Christian Pfefferkorn, MD
Klinik und Poliklinik für Anästhesiologie
Zentrum für Anästhesiologie und Intensivmedizin
Universitätsklinikum Hamburg-Eppendorf
Martinistr. 52
20246 Hamburg
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Table of Contents
1.
Principal Investigators‘ data
2.
Table of Abbreviations
3.
Purpose of the Study
4.
Prior Knowledge in the Field
5.
Study Conception and Project Outline
5.1
primary and secondary Endpoints
5.2
principal Design of the Study
5.3
sample size
5.4
Criteria for In- and Exclusion
5.5
Randomisation
5.6
Clinical anaethesiologic and intensive Care of the Participants
5.7 
Methods of statistical Evaluation
5.8
biometric Parameters and Timepoints 
6.
Literature
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1. Principal Investigators‘ data
1.1 Name and Title of the study‘s principal investigator:
Prof. Dr. med. J. C. Kubitz,  Deputy Director, Clinic for Anaesthesiology, Center for 
Anaesthesiology and Intensive Care,  University Hospital Hamburg-Eppendorf, Germany
1.2 Research Fellow and Deputy to Prof. Kubitz
Dr. med. Eike Christian Pfefferkorn,  Physician/Fellow, Clinic for Anaesthesiology, Center 
for  Anaesthesiology  and  Intensive  Care,   University  Hospital  Hamburg-Eppendorf, 
Germany
2. Table of Abbreviations
ANOVA
analysis of variance
ASA
American Society of Anesthesiology
BNP
brain natriuretic peptide
CPR
cardiopulmonal resuscitation
CRP
C-reaktive protein
ECMO
extracorporal membrane oxygenation
GOT
Glutamate-Oxalacetate-Transaminase
GPT
Glutamate-Pyruvate-Transaminase
HR
heart rate
IL
Interleukin
MAP
mean arterial pressure
NSE
neuron-specific enolase
PCT
Procalcitonin
S1P
Sphingosin-1-Phosphate
TNF
tumor necrosis factor
CVP
central venous pressure
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3. Purpose of the Study
A cardiac arrest with subsequent cardiopulmonary resuscitation (CPR) is even in case of 
a successful return of spontaneous circulation regularly associated with critical ischemia 
of body tissue. Together with damage caused by reperfusion, this is causing a systemic 
inflammatory reaction with release of cascades of pro- and antiinflammatory cytokines, 
taking part in impairing the clinical outcome of the patient.
Yet,  for  many  patients  it  is  even  impossible  to  reconstitute  a  proper  spontaneous 
circulation in the course of a mechanical and pharmaceutical CPR. Nowadays some of 
those, under certain circumstances, might be available for temporary support by veno-
arterial extracorporal membrane oxygenation (va-ECMO)
To establish this device, a physican is installing central venous and arterial intravascular 
catheters during the course of the CPR. Those are then connected to an external system 
consisting of a pumping unit and a membrane for gas exchange, the oxygenator. This 
veno-arterial ECMO thus constitutes a modified version of a heart-lung-machine and is 
capable of performing a temporal and partial cardio-pulmonary bypass, relieving stressed 
heart and lung of the patient from a certain workload. The system‘s maintenance is 
performed by specifically trained physicians and technicians. It‘s modular concept allows 
for the exchange of certain parts with only minor or even entirely without interruptions in 
therapy. Thus, the additional implementation of a adsorber module as performed in this 
study, does not constitute a relevant threat to patient safety and survival.
As mentioned above, the concept of va-ECMO in resuscitated patients is to disburden 
vital organs in a critical phase and thus to facilitate their recovery under supportive 
intensive care and/or to get time to initiate further procedures in order to eliminate the 
original cause for cardiopulmonary arrest.
In this study, we aim to show, whether patients after CPR with subsequent va-ECMO 
profit from an additional modulation of the inflammatory reaction via hemoadsorption 
(Cytosorb®) in terms of levels of inflammatory cytokines and ultimaltely in organ function 
and survival.
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4. Prior Knowledge 
Patients with cardiopulmonary arrest and subsequent CPR are regularly harmed by a 
subsequent systemic inflammatory reaction with many parallels to those suffering from 
sepsis. In both groups, there is a significant increase in the levels of pro-inflammatory 
cytokines as interleukin 6 (IL-6). According to present data, there seems to be a positive 
correlation between the individual level of this increase and terminal mortality of the 
patients  (1).
With hemoadsorption (Cytosorb®, MedaSorb Technologies, Princeton, N.J., USA), a 
device  for  effective  elimination  of  cytokines  like  tumor  necrosis  factor  α  (TNF-α), 
interleukine 6 (IL-6) and 8 (IL-8) from the patient‘s bloodstream is available. This device 
is  CE-certified  for  a  use  in  extracorporal  circulation  and  has  been  in  clinical  use 
worldwide for successful adsorbtion of cytokines, yet as to our knowledge never for 
routine elimination of circulating cytokines in a post-resuscitation setting so far.
Previous  studies  were  able  to  establish  the  capability  of  the  Cytosorb  adsorber  to 
eliminate IL-6, interleukine 10 and TNF-α from the serum and reduce the mortality under 
severe sepsis in an animal model (2). 
As for the clinical application in humans, there are several case reports attributing a 
positive  outcome  for  severely  affected  patients  to  the  use  of  hemoadsorption.  A 
significant reduction of cytokines by the device has been shown in patients  under sepsis 
(4),  systemic inflammation caused by sepsis  (5) and systemic inflammation without 
sepsis (6) (own publication, submitted).
As to our knowledge, there is currently no data available for the application of this device 
in severe systemic inflammation after cardiac arrest, CPR or va-ECMO subsequent to the 
named conditions. 
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5. Study Conception and Project Outline
5.1
primary and secondary endpoints
In this study, we aim to show that hemoadsorption (Cytosorb®) is a viable option to 
reduce serum levels of proinflammatory cytokines in patients under va-ECMO after CPR. 
Specifically, our hypothesis constitutes significantly lower levels of IL-6 and TNF-α in 
patients undergoing hemoadsorption for 48 hours compared to a control group receiving 
standard medical care at va-ECMO during a 72 hours-timeframe. 
Primary outcome parameters
Laboratory  parameters  expressing  an  inflammatory  response  constitute  the  primary 
outcome of our study. Thus,
IL-6, TNF-α, S1P, PCT, CRP, leucozytes
are to be measured at time points 0,6,12,24,48 and 72 hours after administration to va-
ECMO.
Secondary outcome parameters
Those are supposed to reflect secondary and tertiary effects of the hemoadsorption on 
organ function and overall survival of the patients:
1. Laboratory and clinical parameters of inflammation and organ damage/dysfunction 
(cardiovasculary, pulmonary, hepatic, renal, neuronal):
 
•
NSE,  (free)  hemoglobine,  haptoglobine,  BNP, Troponine,  Creatinekinase, 
Myoglobin, GOT, GPT, Creatinine
•
cardiovasculary: (MAP, CVP, HR,. echocardiographic parameters)
•
pulmonary: oxygenation/decarboxylation,  acid-base-balance by blood gas  
analysis
  
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2. Parameters of treatment: 

Cardiovasculary:  Dependence  on  inotropics,  and  vasopressors,  volume 
substitution or elimination, 

pulmonary: relevant parameters of ventilation

additional organ replacement therapy (dialysis, hepatic replacement)
3. Parameters of terminal outcome 

mortality within the first 30 days after inclusion into the study

length of stay in intensive care/in hospital
5.2
Principal study desing
The study is single-centered, prospective, controlled and randomized.
5.3
Sample size
We expect a difference of 20-30% in serum concentration of IL-6 at 24 hours after 
inclusion (about 60µg/L difference at total levels of 200-300µg/L, standard deviation 
90µg/L). With 18 patients per group, the study could determine a significant difference 
between the groups with a power of 90% and an error propability of 5% by ANOVA.
To attribute for post-hoc exclusion or drop-out of participants with an estimated rate of 
10%, we suggest a sample size of 20 patients per group, adding to a total of 40 
participants in the study  
This calculation is based on the publication of Adrie C. Et al. (1) and on a previous study 
performed in our department (publication pending).
5.4
 Criteria for In- and Exclusion
As our hypothesis proposes a relevant effect on any person undergoing treatment by 
va-ECMO post CPR, the criteria for in- and exclusion of study participants are in 
accordance with the clinical indication for this procedure as specified in the standard 
operating procedures of the University Cardiac Arrest Center Hamburg:
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Indications:

Age: 18 to 75 years

cardiopulmonary arrest with 
o
a potentially reversible cause
o
an initially observed rhythm qualifying for defibrillation and 
o
sufficient  CPR prior to va-ECMO
relative contraindications:

severely lowered pH and/or severely increased lactate in arterial blood gas 
analysis at the time of evaluation

protracted CPR for >30 minutes prior to evaluation for va-ECMO
absolute contraindications:

Do-not-resuscitate (DNR)-order stated by the patient prior to current event

context of palliative care 

severe persisting neurological impairment, proven or highly likely at the time of 
evaluation for va-ECMO

severe trauma

relevant acute hemmorhagic event 

presence of  comorbidities with severe reduction of life expectancy (like, but not 
limited to chronic pulmonary disease, chronic heart failure prior to event, hepatic 
cirrhosis, malignoma) 
5.5
Informed consent
Due to the fact, that the patients are regularly expected to be unconscious at the 
time of evaluation for va-ECMO and thus for inclusion in our study and any delay 
e.g. for consultation of a legal representative is not feasible in an emergency 
context, the primary inclusion into the study goes in accordance with the clinical 
criteria stated above. A retrospective informed consent has to be sought at the 
earliest possible moment from a legal representative or the patient itself, should 
the latter regain sufficient consciousness. In case of secondary disapproval and 
thus, drop-out from the study, samples and data gathered up to that time are 
handled in accordance with state and federal German law. This procedure has 
specifically been evaluated and approved by the responsible ethics committee.
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5.6
 Randomization
Randomization is performed at the time of establishment of va-ECMO. Drawing without 
returning of prepared sealed envelopes will ensure an identical size of 20 participants 
each for control and intervention groups .
5.7
Clinical anaethesiologic and intensive Care of the Participants
The general anaethesiologic and intensive care is not affected by inclusion into this study. 
All procedures are conducted in accordance with therapeutic standards of our hospital, 
referencing best medical practice and applicable guidelines.
The sample size to analyze the cytokine levels is estimated to amount to 5ml per time 
point. 
5.7. Statistical analysis
Statistical analysis is conducted using the software package SPSS. To characterize the 
patients, we are going to conduct descriptive analytics in dependence on the statistical 
distribution of variables. 
Continuous variables like hemodynamic and laboratory parameters are analyzed using a 
multifactorial ANOVA or a mixed lineary model.
Nominal or categorized variables are going to be analyzed in four-to-multi-square-tables 
with chi-square-tests or Fisher‘s exact test.
     5.8. Time points and parameters
Time points:
1) on administration to  va-ECMO
2) 6 hours post administration to  va-ECMO
3) 12 hours post administration to  va-ECMO
4) 24 hours post administration to  va-ECMO
5) 48 hours post administration to  va-ECMO
6) 72 hours post administration to  va-ECMO
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Parameters
1. inflammatory:

IL-6

TNFα

S1P

PCT

CRP

leukozytes
2. cardiocirculatory

MAP, CVP, HR

Dependence on external inotropes or vasopressors

BNP, Troponine, Creatinekinase, Myoglobine, Haptoglobine

echocardiographic parameters
3. gas exchange in arterial blood gas analysis

partial pressures of Oxygen and Carbon dioxide 

pH and lactate 

Base excess
4. hepatic

GOT, GPT
5. renal

diuresis

fluid balance

serum creatinine

glomerularic filtration rate estimated by CKD-EPI-formula
Additionally, we are going to evaluate demographic data (functional status in accordance with 
ASA-classification, age, sex, size, total body weight) and periprocedural parameters with 
specific focus on CPR (duration/time prior to va-ECMO, cause of arrest).
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Overview of the study
Principal 
investigator
Prof. Dr. Jens Kubitz
Title
HaemoAdsorption Nach Reanimation An ECMO (HANRAE)
Hypothesis
Additional  hemoadsorption  (Cytosorb®)  in  the  extracorporal 
circulation established by va-ECMO in patients after cardiac arrest 
and CPR reduces the levels of IL-6 and TNFα in the serum.
Target population
Patients under va-ECMO subsequent to cardiac arrest and CPR
Primary endpoints
Levels of IL-6 und TNFα  in the patients‘ serum in an interval of 72 
hours post resuscitation
Secondary endpoints

Laboratory  and  clinical  parameters  of  inflammation  and 
organ  damage/dysfunction  (cardiovascular,  pulmonary, 
hepatic, renal, neuronal)  

Parameters of intensive  care treatment (e.g. ventilation, 
additional organ replacement therapy)

Parameters of terminal outcome (mortality)
study design
single-centerd, prospective, controlled, randomized
inclusion criteria

Age ≥ 18 years

cardiac arrest with  CPR

application  of  va-ECMO  for  insufficient  spontaneous 
circulation
exclusion criteria

contraindication  for  va-ECMO  in  accordance  with  the 
standard operating procedures of the University Cardiac 
Arrest Center Hamburg  ECMO bei Reanimation – see 5.4 
for details
sample size
We expect a difference of 20-30% in serum concentration of IL-6 
at 24 hours after inclusion (about 60µg/L difference at total levels 
of 200-300µg/L, standard deviation 90µg/L). With 18 patients per 
group, the study could determine a significant difference between 
the groups with a power of 90% and an error of propability of 5% 
by ANOVA.
To attribute for post-hoc exclusion or drop-out of participants, we 
suggest a sample size of 20 patients per group, adding to a total of 
40 participants in the study.
randomization
Randomization  is  performed  as  drawing  without  returning  to 
ensure an identical size for control and intervention groups.
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Hamburg, 29.12.2017
6. Literature
1.
Adrie  C,  Laurent  I,  Monchi  M,  Cariou  A,  Dhainaou  JF,  Spaulding  C. 
Postresuscitation disease after cardiac arrest: a sepsis-like syndrome? Current 
opinion in critical care. 2004;10(3):208-12.
2.
Kellum  JA,  Song  M,  Venkataraman  R.  Hemoadsorption  removes  tumor 
necrosis factor, interleukin-6, and interleukin-10, reduces nuclear factor-kappaB 
DNA binding, and improves short-term survival in lethal endotoxemia. Critical 
care medicine. 2004;32(3):801-5.
3.
Peng  ZY,  Carter  MJ,  Kellum  JA.  Effects  of  hemoadsorption  on  cytokine 
removal  and  short-term  survival  in  septic  rats.  Critical  care  medicine. 
2008;36(5):1573-7.
4.
Tomescu DR, Olimpia Dima S, Ungureanu D, Popescu M, Tulbure D, Popescu 
I.  First  report  of  cytokine  removal  using  CytoSorb(R)  in  severe  noninfectious 
inflammatory syndrome after liver transplantation. The International journal of 
artificial organs. 2016;39(3):136-40.
5.
Bruenger F, Kizner L, Weile J, Morshuis M, Gummert JF. First successful 
combination of ECMO with cytokine removal therapy in cardiogenic septic shock: 
a case report. The International journal of artificial organs. 2015;38(2):113-6.
6.
Bernardi MH, Rinoesl H, Dragosits K, Ristl R, Hoffelner F, Opfermann P, et 
al. Effect of hemoadsorption during cardiopulmonary bypass surgery - a blinded, 
randomized,  controlled  pilot  study  using  a  novel  adsorbent.  Critical  care. 
S016;20:96.
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