Efficacy and Safety of Anisodamine Hydrobromide Combined with Low-molecular-weight Heparin for the Treatment of Sepsis Patients: Study Protocol for a Multicenter Randomized Controlled Trial

Efficacy and Safety of Anisodamine Hydrobromide Combined with Low-molecular-weight Heparin for the Treatment of Sepsis Patients: Study Protocol for a Multicenter Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Efficacy and Safety of Anisodamine Hydrobromide Combined with Low-molecular-weight Heparin for the Treatment of Sepsis Patients: Study Protocol for a Multicenter Randomized Controlled Trial Ying Chen, Shuxing Wei, Hongmeng Dong, Wenqing Ji, Da Zhang, Yali Xu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4011079/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The objective of this study was to compare the effects of traditional treatment with those of anisodamine hydrobromide (Ani HBr) combined with low-molecular-weight heparin (LMWH) in the treatment of sepsis in hopes that this therapy will provide alternatives for the treatment of sepsis. This was a randomized, placebo-controlled, open-label, multicenter trial involving patients with sepsis recruited from seven emergency departments in Beijing, China. Patients diagnosed with sepsis will be randomly assigned to either the treatment or control group at a 1:1 ratio. The treatment group will receive Ani HBr combined with LMWH, while the control group will receive conventional treatment. A total of 782 sepsis patients will be recruited, and interim analysis will be conducted. The primary endpoint of the study was the 28-day mortality rate. The secondary endpoints included the lactate clearance rate at 6 hours, 24 hours, and 72 hours, the duration of ICU and hospital stay, the number of days without organ failure, the number of days with vasopressor use within 28 days, the septic shock conversion rate, the 28-day mortality rate of septic shock, and the 72-hour sublingual microcirculation. If the combination therapy of Ani HBr and LMWH demonstrates superior efficacy compared to conventional treatment, this study will provide valuable insights into the treatment of septic shock and potentially contribute to reducing the mortality rate associated with this condition. Trial registration: NCT05634057 (https://register.clinicaltrials.gov/). Anisodamine hydrobromide heparin randomized controlled trial sepsis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction After a 15-year hiatus, the introduction of Sepsis-3 in 2016 marked a significant milestone. Sepsis is a life-threatening condition characterized by organ dysfunction resulting from a dysregulated host response to infection, surpassing the lethality of a mere infection and necessitating urgent recognition [ 1 ]. Within the spectrum of sepsis cases, septic shock represents a subset with notably higher mortality rates. Both severe sepsis and septic shock are leading causes of mortality among patients admitted to the intensive care unit (ICU) [ 2 ]. Sepsis remains the predominant cause of death overall, contributing to one-third to one-half of all hospital deaths [ 3 ]. A meta-analysis of data collected prior to 2022 indicated that the estimated combined in-hospital mortality rates for hospital-wide sepsis and ICU sepsis in China were 26% (95% CI: 16–36%) and 40% (95% CI: 34–47%), respectively [ 4 ]. Another meta-analysis covering the period from 2009 to 2019 across Europe, North America, and Australia revealed a 30-day mortality rate of 24.39% in patients with sepsis, with the 30-day mortality for septic shock patients reaching 34.73% [ 5 ]. A random-effects meta-analysis consolidating global data from 2015 to 2019 estimated a hospital-wide inpatient mortality rate of 26.7% and an inpatient mortality rate of 41.9% for ICU patients with sepsis [ 6 ]. According to the Surviving Sepsis Campaign, the treatment of sepsis and septic shock encompasses a triad involving hemodynamic resuscitation with crystalloids, vasopressor infusion, and the administration of antimicrobials within the first hour of diagnosis [ 7 ]. In recent years, numerous treatment strategies have been explored to alleviate the disease burden associated with septic shock. For example, combination therapy involving hydrocortisone, vitamin C, and thiamine has been shown to increase the duration of vasopressor-free survival in patients with septic shock [ 8 – 10 ]. Additionally, the use of anisodamine has been explored for its ability to reduce hospital mortality [ 11 ], while the coadministration of iloprost and eptifibatide has been studied for its ability to attenuate endothelial injury and platelet consumption and improve the Sequential Organ Failure Assessment (SOFA) score in patients with septic shock [ 12 ]. Levocarnitine has been investigated for its potential to reduce cumulative organ failure within 48 hours and decrease 28-day mortality in septic shock patients [ 13 ]. However, progress in the foundational scientific knowledge of sepsis has not been commensurate with the introduction of new sepsis medications. A more accurate assessment of this situation would be that many new drugs have been developed, but none have demonstrated reproducible benefits to patients in clinical trials. AniHBr is derived from the root of the plant Scopolia tangutica Maxim. in China and has been produced on a large scale since 2016. AniHBr acts as an M-choline receptor antagonist and is commonly used as a peripheral anticholinergic drug in clinical practice due to its minimal central side effects. In traditional Chinese medicine, AniHBr is utilized to treat various diseases and has effects such as relieving vasospasm (particularly in microvessels), improving microcirculation, relaxing smooth muscle, suppressing glandular secretion, inhibiting shock, dilating pupils, and providing analgesia [ 14 ]. Anisodamine (654-2) and AniHBr (654-1) are both traditional Chinese medicines that are M receptor antagonists. In 2021, a randomized controlled trial revealed no evidence that anisodamine (654-2) can reduce hospital mortality among critically ill adults with septic shock treated in the intensive care unit [ 11 ]. Previous animal experiments have demonstrated that AniHBr can significantly reduce the serum levels of creatine kinase and lactic acid in rats with lipopolysaccharide-induced septic shock while also improving hemodynamics [ 15 ]. AniHBr, a traditional Chinese medicine, was shown in early studies by our research team to be a potentially crucial adjunctive medication in routine treatment. It may reduce the 28-day mortality, 7-day mortality, and hospital mortality rates in patients with septic shock, along with lowering lactate levels [ 16 ]. However, there is still a lack of conclusive evidence from well-designed clinical trials supporting its efficacy in the treatment of sepsis. With a deepening understanding of the relationship between disseminated intravascular coagulation (DIC) and sepsis, the use of low-molecular-weight heparin (LMWH) in the treatment of sepsis and septic shock has gained increasing attention, and its effectiveness is increasingly recognized. Recent studies have indicated that early administration of LMWH can significantly inhibit thrombocytopenia and improve tissue perfusion, and two systematic reviews have highlighted the potential benefits of low-molecular-weight heparin for survival in sepsis patients without a major bleeding risk [ 17 , 18 ]. This study aimed to investigate the addition of AniHBr combined with low-molecular-weight heparin to the conventional treatment of sepsis patients, providing a new approach for sepsis treatment and potentially reducing mortality rates associated with this condition. However, conclusive evidence from well-designed clinical trials supporting its efficacy is lacking. Materials and methods Study design and setting This was a prospective, multicenter, randomized study conducted at seven participating hospitals in Beijing, China. Patients with sepsis will be enrolled between December 2023 and February 2025. The investigators at each participating center will screen potential patients with sepsis to determine their eligibility for the study. Prior to commencing the study, the study underwent review and received approval from the institutional review board of Beijing Chaoyang Hospital, which is affiliated with Capital Medical University (Approval No.2022-620-1), as well as the ethics committee of each participating center. Informed consent will be obtained from all participants or their next of kin before their inclusion in the study. The study was registered on the Clinical Trials website. gov (registration no. NCT05634057). Inclusion and exclusion criteria The inclusion criteria for this study were as follows: 1) Patients must be over 18 years old. 2) Patients must have a diagnosis of sepsis, as defined by The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) [ 1 ]. 3) Patients must be willing to provide informed consent by signing the consent form. The exclusion criteria for this study were as follows: 1) Patients who were expected to die within 24 hours after enrollment. 2) Contraindications to low-molecular-weight heparin and scopolamine butylbromide drugs. 3) Thrombotic disease requiring treatment with low-molecular-weight heparin. 4) Patients with terminal-stage malignancies, severe immunodeficiency, immunosuppression, severe liver or kidney dysfunction (defined as liver or kidney SOFA score ≥ 3 points), etc. 5) Pregnant or lactating women. 6) Patients participating in other clinical trials. The methods of recruiting subjects involved utilizing hospital records, briefing family members and/or patients about the study by doctors and researchers, and allowing family members and/or patients to make a decision regarding participation in the trial. Diagnostic criteria for sepsis (including septic shock) [ 1 ] 1. Patient with suspected infection. 2. qSOFA ≥ 2. 3. Assessment of evidence of organ dysfunction 4. SOFA ≥ 2. 5. Despite adequate fluid resuscitation, vasopressors are required to maintain a MAP ≥ 65 cm Hg and a serum lactate level > 2 mmol/L. Intervention In the control group, the initial treatment strategy followed the recommendations outlined in the Surviving Sepsis Campaign (SSC) guidelines [ 7 ] within the first 24 hours after the diagnosis of sepsis. This strategy included two variables: 1. The following resuscitation measures were implemented within the first 6 hours of septic shock: Measurement of lactate levels Collection of cultures prior to initiating antibiotic treatment Administration of broad-spectrum antibiotics Administration of fluids and vasopressors to achieve a mean arterial pressure (MAP) > 65 mmHg 2. All treatment measures were implemented within 24 hours, including the following: Consideration of low-dose corticosteroids in patients with septic shock Blood glucose control The plateau pressure was monitored and controlled to ensure protective mechanical ventilation. In the intervention group, a combination therapy approach was employed, which included Ani HBr injection, low-molecular-weight heparin, and traditional treatment as per the SSC guidelines. The intervention protocol was as follows: Ani HBr Injection: The dosage of Ani HBr injected was 2.0 mg/(kg*d), which was administered via a micropump at a constant rate continuously for 3 days. Low-molecular-weight heparin: The dosage range for low-molecular-weight heparin is limited to 3000–6000 U, and heparin is administered subcutaneously once daily for 3 days. Study endpoint The primary endpoint of this study was 28-day mortality, which was assessed by determining the mortality rate of patients over 28 days. The patients will be followed up for 28 days. In the event that patients are discharged earlier than 28 days, their survival time will be recorded as of day 28 after admission or diagnosis with septic shock. The secondary endpoints of the study included the following: Lactate clearance rate: The rate of lactate clearance will be evaluated at specific time points, namely, 6 hours, 24 hours, and 72 hours after admission. This will involve measuring the reduction in lactate levels, which serve as an indicator of the patient's response to treatment. Length of stay in the ICU and hospital: The duration of ICU and hospital stay will be recorded, providing insights into the patient's healthcare resource utilization and recovery trajectory. Organ failure-free days: Organ failure will be evaluated using the Sequential Organ Failure Assessment (SOFA) score. The number of organ failure-free days was calculated, indicating the duration during which the patient did not experience organ failure. Number of days with vasopressor use within 28 days. Septic shock conversion rate. The 28-day mortality rate of septic shock patients. The 72-hour sublingual microcirculation. These secondary study endpoints aim to provide additional information on the effectiveness of the intervention and its impact on various clinical outcomes related to sepsis. Adverse events Patient safety will be a paramount consideration throughout the study, and measures will be in place to monitor and address any potential adverse events. At each study visit, the safety of the patients will be carefully assessed and monitored. Adverse events [ 19 ] that are closely monitored include but are not limited to: 1. New-onset psychosis: Any occurrence of new psychiatric symptoms or changes in mental status will be thoroughly evaluated and reported. 2. Urinary retention: Instances of urinary retention, where the patient experiences difficulty or inability to empty the bladder, will be monitored and documented. 3. Significant hypotension: Patients with severe low blood pressure will be closely monitored and managed appropriately. 4. Tachycardia: Instances of rapid heart rate exceeding the normal range will be monitored and documented. In the event of any adverse event, patients will be promptly informed and instructed to discontinue their participation in the study. Patient safety is of utmost importance, and the study protocol includes provisions to ensure that the well-being and safety of the patients are prioritized. This includes closely monitoring adverse events and taking appropriate actions to mitigate any risks or harm to the patients involved in the study. Data collection In this study, data collection will be conducted by research coordinators using paper data forms. The case report form (CRF) will be written in Chinese to facilitate effective communication among investigators. To ensure accuracy, the correctness of the original CRFs will be carefully verified. Subsequently, a database will be established using an electronic data capture (EDC) system. The data will be entered into the database by two trained data entry clerks independently. Following the initial data entry, a process of double entry verification will be conducted to compare the entries and identify any inconsistencies or errors. In case of any inconsistencies or discrepancies found within the database, a thorough item-by-item review of the original record table will be performed for proofreading and correction. Once all the necessary corrections and verifications are completed, the database will be locked to prevent further changes. This data collection and entry process ensures the integrity and accuracy of the collected data, reducing the chances of errors or discrepancies during the study analysis phase. Group sequential analysis and sample size estimation This study follows a superiority trial design and employs the group sequential method to estimate the required sample size. Considering the cost associated with Ani HBr and the potential effectiveness of interim analyses, the trial has provisions to stop early under certain circumstances. The reasons for early termination of the clinical trial may include the following: 1. Serious toxicity or adverse events: If there are significant safety concerns or unexpected severe adverse events associated with the treatment, the trial may be stopped early to ensure patient safety. 2. Established benefit: If interim analyses indicate a clear and statistically significant benefit of the treatment being investigated, it may be considered unethical to continue the trial, and it may be stopped early to provide the treatment to a larger population. 3. Design or logistical difficulties that are too serious to fix: In situations where there are significant design or logistical challenges that cannot be resolved without compromising the integrity or validity of the trial, the study may be stopped early. To facilitate the design of group sequential trials, the R package "gsDesign" will be utilized. This package allows for the implementation of group sequential analyses in which promising treatments can be selected at various interim analyses. The group sequential method enables efficient monitoring of treatment effects and provides the flexibility to potentially stop the trial early if specific criteria are met. By incorporating the group sequential method and the ability to perform interim analyses, this trial aims to optimize the use of resources, reduce costs, and efficiently evaluate the effectiveness and safety of the treatment under investigation. Parameters : Based on the information provided, it appears that a group sequential design will be implemented with lower bound spending under the null hypothesis, three-stage analyses, 80% power, and a 2.5% (1-sided) type I error rate. The following details were specified: 1. The mortality rate in the control group is assumed to be 29%, and the new intervention is expected to reduce the mortality rate by 9%. 2. Fixed sample size: The sample size for the fixed design with no interim was 782, which was calculated by PASS21. 3. Timing of interim analyses: Interim analyses will be conducted at three equally spaced accrual sample sizes: 266, 531, and 796 (Table 1 ). 4. Spending functions: The Hwang-Shih-DeCani [ 20 ] spending function will be used, with lower bound spending with gamma=-2 and alpha spending with gamma=-4. The expected behavior of the trial and the sample size calculations are summarized as follows: Maximum total sample size: The maximum total sample size for the trial was 796. Alpha spending: Table 2 provides the alpha spending function, which indicates the cumulative type I error rate at each interim analysis. Beta spending: Table 3 presents the beta spending function, which indicates the cumulative type II error rate at each interim analysis. Boundary crossing probabilities: Figure 2 illustrates the upper boundary crossing probabilities. If any interim analysis crosses the upper boundary, the trial will be stopped. However, the trial will continue if any analysis crosses the lower boundary. Spending function plot: Figure 3 displays the spending function plot for alpha and beta, derived using the Hwang-Shih-DeCani spending function. Expected sample size: Figure 4 shows the expected sample sizes for different underlying risk factors. At the assumed risk difference of 0.1, the expected sample size is estimated to be 661, which is smaller than the fixed sample size of 782. By implementing the group sequential design with the specified parameters, the trial aims to achieve more efficient sample size utilization while maintaining sufficient statistical power to evaluate the effectiveness of the new intervention. Table 1 Upper and lower bounds expressed at different scales ---------Lower bounds--------- --------- Upper bounds--------- Analysis* n.I** N*** Z**** Nominal p***** Spend+ Z Nominal p Spend++ 1 0.3393 266 -1.06 0.1446 0.1446 3.01 0.0013 0.0013 2 0.6786 531 -0.23 0.4082 0.2817 2.55 0.0054 0.0049 3 1.0179 796 2.00 0.9772 0.5487 2.00 0.0228 0.0188 Total 0.9750 0.0250 *3 equally spaced analyses. **Average sample number/expected sample size is computed using n.I. at each analysis times the probability of crossing a boundary at that analysis. If no boundary is crossed at any analysis, this is considered stopping at the final analysis. ***Expected sample size for each analysis. **** Test statistics of each analysis. *****P value of each analysis. ++β-spending of each analysis. ++αspending of each analysis. Table 2 Upper boundary (power or Type I Error) Analysis δ 1 2 3 Total E{N} 0.00 0.0013 0.0049 0.0187 0.025 642.5 0.10 0.0840 0.3284 0.3876 0.8000 661.2 δ represents the risk difference. Upper boundary crossing probabilities and assume that any cross stops the trial. Table 3 Lower boundary (futility or Type II Error) Analysis δ 1 2 3 Total 0.00 0.1446 0.2817 0.5487 0.975 0.10 0.0036 0.0045 0.1919 0.200 δ represents the risk difference. We set lower bound spending under the null hypothesis with a nonbinding lower bound and assume that any cross stops the trial. Randomization In this study, blocked randomization was employed to allocate subjects to either the combination therapy group or the control group. The randomization was performed at a 1:1 ratio using blocks of sizes 2,4,6,8 to 796 subjects. To ensure random assignment concealment, a web-based central random system was utilized. The person in charge of each center accessed the network system and entered the basic information of the subjects who met the inclusion and exclusion criteria. The central random system automatically assigned a random number to each subject. Once a random number was assigned, it could not be assigned to another subject. It is important to note that subjects who failed to complete the entire study could not be included. Random sequence allocation and allocation hiding were implemented through the use of a central stochastic system. This ensured that the allocation process was unbiased and concealed from the investigators involved in the study. This study is an open-label trial, meaning that both the researchers and participants are aware of the treatment assignment. The protocol details can be found in Fig. 1 , which provides a summary of the study design and procedures. Statistical analysis The primary and secondary efficacy analyses in this study were conducted using the intention-to-treat (ITT) analysis set. The analysis will involve baseline variables, which include both measurement data and count data. The measurement data are presented as the mean (standard deviation, SD) or number (percent), while the count data are expressed as the median and interquartile range. To compare the means of continuous random variables between the two groups, t tests will be utilized. The proportions test will be employed for dichotomous response variables, and the log-rank test will be used for censored survival data. For the binary variable of mortality, a chi-square test will be used for the comparison. A mixed linear model will be utilized to assess the effect of treatment on outcomes and to perform repeated-measures analysis of variance. The statistical tests will be two-sided, and a p value less than 0.05 will be considered to indicate statistical significance. All the statistical analyses will be conducted using R software, specifically version 4.3.1. R is a widely used statistical programming language that provides a range of statistical functions and packages for data analysis. By employing appropriate statistical methods and software, this study aimed to analyze the data accurately and determine the significance of the treatment effect on the evaluated outcomes. Discussion Sepsis often disrupts the systemic distribution of blood flow to organ systems through vasodilation and disturbances in microcirculation. In the context of septic shock, endothelial dysfunction, glycocalyx degradation, alterations in blood cell rheology (reduced red blood cell deformability), and an imbalance in levels of vasoactive substances can lead to changes in microcirculation. This may alter the matching of blood flow to tissue demands. Therefore, optimizing microcirculation should be prioritized during the resuscitation process. The authors emphasize that while early-stage resuscitation and the restoration of macrocirculatory variables (cardiac output, mean arterial pressure, etc.) may improve microcirculatory flow, monitoring microcirculation and implementing interventions tailored to microcirculatory resuscitation are essential to prevent harm to microcirculation during interventions in macrocirculation [ 22 ]. Coagulation activation is one of the mechanisms triggered by the innate immune system to recognize invading pathogens, aiding in their clearance. During sepsis, increased tissue factor expression, downregulation of natural anticoagulant pathways, and inadequate fibrinolysis contribute to increased thrombin generation and clot formation. Dysregulated coagulation activation may lead to microvascular thrombosis and hypoxia, causing tissue damage in sepsis. This, in turn, can result in disseminated intravascular coagulation, potentially causing organ dysfunction if severe enough [ 23 ]. The key to treating sepsis-induced coagulopathy is the rapid and timely treatment of underlying infections. Strategies widely studied aim to suppress prothrombotic effects, with heparin and its derivatives commonly used for preventing deep vein thrombosis in sepsis treatment [ 25 ]. Two meta-analyses have indicated a potential association between heparin use and reduced mortality in sepsis patients [ 26 , 27 ]. Yiting Tang et al. suggested that heparin prevents the caspase-11-dependent immune response and lethality in sepsis, independent of its anticoagulant properties. They proposed the therapeutic use of modified heparin or low-dose heparin, which lacks anticoagulant activity but can block HMGB1-mediated intracellular LPS delivery and heparanase-mediated glycocalyx degradation. This approach might offer a strategy to minimize bleeding risks [ 28 ]. However, Iba T et al. suggested that heparin, by activating anticoagulant proteins and inhibiting coagulation, lacks sufficient confirmatory data for its use. Therefore, the potential risk of heparin-induced thrombocytopenia (HIT) should be carefully considered when assessing the risk-benefit balance [ 29 ]. 654-1, which is derived from the roots of Scopolia tangutica Maxim. in China, has been produced on a large scale since 2016. Acting as an M-choline receptor antagonist, it is commonly used as a peripheral anticholinergic drug in clinical practice due to minimal central side effects. In traditional Chinese medicine, 654-1 is used to treat various diseases, as it relieves vasospasm, improves microcirculation, relaxes smooth muscle, suppresses glandular secretion, has anti-shock properties, dilates the pupils, and provides analgesia [ 14 ]. Animal experiments demonstrated that 654-1 could significantly reduce the serum levels of creatine kinase and lactic acid in rats with lipopolysaccharide-induced septic shock while improving hemodynamics [ 15 ]. In a previous randomized controlled trial (RCT), 654-1 was shown to be a potentially important adjunctive therapy in conventional treatment, reducing the 28-day mortality, 7-day mortality, and hospital mortality rates of septic shock patients, as well as lowering lactate levels. However, the results primarily indicated potential benefits for patients with severe disease severity [ 16 ]. While the effective dosage has been identified through preliminary exploration, this trial expands the study population and introduces an innovative combination of two drugs. The response of patients to this combination remains unknown, necessitating an adaptive design to promptly adjust drug timing, dosage, and sample size. The goal of adaptive trial design is to identify intervention measures with therapeutic effects more quickly than traditional trial designs. It focuses on patient populations where the drug is effective. An ideal adaptive trial design could lead to the early cessation of ineffective drugs and the simultaneous assessment of different dosing regimens of potentially effective drugs [ 32 ]. Compared to traditional clinical trial designs with predefined features that remain constant throughout the trial, adaptive design models evolve key trial features during the trial based on predefined rules [ 33 ]. One crucial evolving trial feature is the randomized probability of assigning new subjects to available treatment groups. For example, subjects may be prioritized for assignment to a treatment group that appears to perform better [ 34 ], or similarly, subjects may be prioritized for assignment to doses that seem to increasingly offer clinically relevant benefits with acceptable side effects [ 35 , 36 ]. These adjustments enhance the efficiency of clinical trials, provide more opportunities for successful learning goals, and offer a better understanding of treatment effects, thereby contributing to more effective designs for subsequent studies. Declarations Ethics approval and consent to participate The protocol was reviewed and approved by the Institutional Review Board and Medical Ethics Committee of Beijing Chao-Yang Hospital (Ethical approval number: 2022-ke-620-1) and each participating center. Written informed consents to participate in the study were obtained from participants or their legal guardians. Funding The study was funded by the Capital Research on Special Clinical Application (No. Z211100002921061). Data availability The raw/processed data required to reproduce these findings cannot beshared at this time as the data also forms part of an ongoing study. Consent for publication Not applicable. Conflict of interest The authors declare that they have no competing interests. References Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Jama. 2016;315:801-10. Genga KR, Russell JA, et al. Update of Sepsis in the Intensive Care Unit. J Innate Immun. 2017;9(5):441-455. Cohen J, Vincent JL, Adhikari NK, Machado FR, Angus DC, Calandra T, Jaton K, Giulieri S, Delaloye J, Opal S, Tracey K, van der Poll T, Pelfrene E. Sepsis: a roadmap for future research. Lancet Infect Dis. 2015 May;15(5):581-614. Lei S, Li X, Zhao H, Xie Y, Li J. Prevalence of sepsis among adults in China: A systematic review and meta-analysis. Front Public Health. 2022 Oct 11;10:977094. Bauer M, Gerlach H, Vogelmann T, Preissing F, Stiefel J, Adam D. Mortality in sepsis and septic shock in Europe, North America and Australia between 2009 and 2019- results from a systematic review and meta-analysis. Crit Care. 2020 May 19;24(1):239. Fleischmann-Struzek C, Mellhammar L, Rose N, Cassini A, Rudd KE, Schlattmann P, Allegranzi B, Reinhart K. Incidence and mortality of hospital- and ICU-treated sepsis: results from an updated and expanded systematic review and meta-analysis. Intensive Care Med. 2020 Aug;46(8):1552-1562. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247. Fujii T, Luethi N, Young PJ, et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial. JAMA. 2020 Feb 4;323(5):423-431. doi: 10.1001/jama.2019.22176. PMID: 31950979; PMCID: PMC7029761. Lyu QQ, Zheng RQ, Chen QH, et al. Early administration of hydrocortisone, vitamin C, and thiamine in adult patients with septic shock: a randomized controlled clinical trial. Crit Care. 2022 Sep 28;26(1):295. Hwang SY, Ryoo SM, Park JE, et al. Combination therapy of vitamin C and thiamine for septic shock: a multicenter, double-blinded randomized, controlled study. Intensive Care Med. 2020 Nov;46(11):2015-2025. Yu Y, Zhu C, Zhang Z, et al. Effectiveness of anisodamine for the treatment of critically ill patients with septic shock: a multicenter randomized controlled trial. Crit Care. 2021 Sep 27;25(1):349. Berthelsen RE, Ostrowski SR, Bestle MH, Johansson PI. Coadministration of iloprost and eptifibatide in septic shock (CO-ILEPSS)-a randomized, controlled, double-blind investigator-initiated trial investigating safety and efficacy. Crit Care. 2019 Sep 5;23(1):301. Jones AE, Puskarich MA, Shapiro NI, et al. Effect of Levocarnitine vs Placebo as an Adjunctive Treatment for Septic Shock: The Rapid Administration of Carnitine in Sepsis (RACE) Randomized Clinical Trial. JAMA Netw Open. 2018 Dec 7;1(8):e186076. Eisenkraft A, Falk A. Possible role for anisodamine in organophosphate poisoning. Br J Pharmacol. 2016 Jun;173(11):1719-27. Wan F, Du X, Liu H, He X, Zeng Y. Protective effect of AniHBr on lipopolysaccharide-induced acute kidney injury. Biosci Rep. 2020 Jul 31;40(7):BSR20201812. Zhang F, Mei X, Zhou P, Tian YP, Liu JX, Dong X, Yuan DS, Lin ZF, Zhang L, Lin JH, Li AJ, Deng X, Chen MZ, Yuan SY, Zha JJ, Shi B, Lin ZH, Guo SB. Anisodamine hydrobromide in the treatment of critically ill patients with septic shock: a multicenter randomized controlled trial. Ann Med. 2023;55(2):2264318. Zarychanski R, Abou-Setta AM, Kanji S, Turgeon AF, Kumar A, Houston DS, et al. The efficacy and safety of low-molecular-weight heparin in patients with sepsis: a systematic review and metaanalysis. Critical care medicine. 2015;43:511-8. Fu S, Yu S, Wang L, Ma X, Li X. Unfractionated low-molecular-weight heparin improves the clinical efficacy in adult sepsis patients: a systematic review and meta-analysis. BMC anesthesiology. 2022;22:28. Honore PM, Redant S, Preseau T, Cismas BV, Kaefer K, Barreto Gutierrez L, Anane S, Attou R, Gallerani A, De Bels D. Anisodamine microcirulatory effects in septic shock: be aware of cardiac side effects. Crit Care. 2021 Dec 16;25(1):433. Hwang IK, Shih WJ, De Cani JS. Group sequential designs using a family of type I error probability spending functions. Stat Med 1990;9:1439-45. Cecconi M, Evans L, Levy M, Rhodes A. Sepsis and septic shock. Lancet. 2018 Jul 7;392(10141):75-87. Khanna AK, Karamchandani K. Macrocirculation and Microcirculation: The "Batman and Superman" Story of Critical Care Resuscitation. Anesth Analg. 2021 Jan;132(1):280-283. Fiusa MM, Carvalho-Filho MA, Annichino-Bizzacchi JM, De Paula EV. Causes and consequences of coagulation activation in sepsis: an evolutionary medicine perspective. BMC Med. 2015 May 6;13:105. Taylor FB Jr, Toh CH, Hoots WK, Wada H, Levi M; Scientific Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Hemostasis (ISTH): . Toward definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Hemost . 2001; 86:1327–30 Miranda M, Balarini M, Caixeta D, Bouskela E. Microcirculatory dysfunction in sepsis: pathophysiology, clinical monitoring, and potential therapies. Am J Physiol Heart Circ Physiol. 2016 Jul 1;311(1):H24-35. Zarychanski R, Abou-Setta AM, Kanji S, Turgeon AF, Kumar A, Houston DS, Rimmer E, Houston BL, McIntyre L, Fox-Robichaud AE, Hébert P, Cook DJ, Fergusson DA; Canadian Critical Care Trials Group. The efficacy and safety of heparin in patients with sepsis: a systematic review and metaanalysis. Crit Care Med. 2015 Mar;43(3):511-8. Wang C, Chi C, Guo L, Wang X, Guo L, Sun J, Sun B, Liu S, Chang X, Li E. Heparin therapy reduces 28-day mortality in adult severe sepsis patients: a systematic review and meta-analysis. Crit Care. 2014 Oct 16;18(5):563. Tang Y, Wang X, Li Z, He Z, Yang X, Cheng X, Peng Y, Xue Q, Bai Y, Zhang R, Zhao K, Liang F, Xiao X, Andersson U, Wang H, Billiar TR, Lu B. Heparin prevents caspase-11-dependent septic lethality independent of anticoagulant properties. Immunity. 2021 Mar 9;54(3):454-467.e6. Iba T, Levi M, Levy JH. Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation. Semin Thromb Hemost. 2020 Feb;46(1):89-95. doi: 10.1055/s-0039-1694995. Epub 2019 Aug 23. PMID: 31443111. Rui-Juan X, Hammerschmidt DE, Coppo PA, Jacob HS. Anisodamine Inhibits Thromboxane Synthesis, Granulocyte Aggregation, and Platelet Aggregation: A Possible Mechanism for Its Efficacy in Bacteremic Shock. JAMA. 1982;247(10):1458–1460. Wan F, Du X, Liu H, He X, Zeng Y. Protective effect of anisodamine hydrobromide on lipopolysaccharide-induced acute kidney injury. Biosci Rep. 2020 Jul 31;40(7):BSR20201812. Lang T. Adaptive trial design: could we use this approach to improve clinical trials in the field of global health? Am J Trop Med Hyg. 2011 Dec;85(6):967-70. Opal SM, Dellinger RP, Vincent JL, Masur H, Angus DC. The next generation of sepsis clinical trial designs: what is next after the demise of recombinant human activated protein C?*. Crit Care Med. 2014 Jul;42(7):1714-21. Harhay MO, Wagner J, Ratcliffe SJ, Bronheim RS, Gopal A, Green S, Cooney E, Mikkelsen ME, Kerlin MP, Small DS, Halpern SD. Outcomes and statistical power in adult critical care randomized trials. Am J Respir Crit Care Med. 2014 Jun 15;189(12):1469-78. Lewis RJ, Viele K, Broglio K, Berry SM, Jones AE. An adaptive, phase II, dose-finding clinical trial design to evaluate L-carnitine in the treatment of septic shock based on efficacy and predictive probability of subsequent phase III success. Crit Care Med. 2013 Jul;41(7):1674-8. Dolgin E. Adaptive methods help drug sponsors find best treatment dose. Nat Med. 2014 Apr;20(4):321. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4011079","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":281895897,"identity":"52a2c352-c6bd-4e9f-8eab-01f5c415fbf5","order_by":0,"name":"Ying Chen","email":"","orcid":"","institution":"Beijing Chao-Yang Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Chen","suffix":""},{"id":281895898,"identity":"a092a59a-fe4f-4733-8ba1-2f6f1e5518f3","order_by":1,"name":"Shuxing Wei","email":"","orcid":"","institution":"Beijing Chao-Yang Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shuxing","middleName":"","lastName":"Wei","suffix":""},{"id":281895899,"identity":"fdc69595-6c06-4d71-a4cf-eafac8e722e1","order_by":2,"name":"Hongmeng Dong","email":"","orcid":"","institution":"Beijing Chao-Yang Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hongmeng","middleName":"","lastName":"Dong","suffix":""},{"id":281895900,"identity":"052840e8-7e84-486e-aa4d-30eec77e0958","order_by":3,"name":"Wenqing Ji","email":"","orcid":"","institution":"Beijing Chao-Yang Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wenqing","middleName":"","lastName":"Ji","suffix":""},{"id":281895901,"identity":"6bb826cf-f49f-4194-8adf-facd5d3a40b7","order_by":4,"name":"Da Zhang","email":"","orcid":"","institution":"Beijing Chao-Yang Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Da","middleName":"","lastName":"Zhang","suffix":""},{"id":281895902,"identity":"e4a10160-bb05-4bed-85ec-902f928ddd39","order_by":5,"name":"Yali Xu","email":"","orcid":"","institution":"Beijing Chao-Yang Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yali","middleName":"","lastName":"Xu","suffix":""},{"id":281895903,"identity":"e8e78e2c-fd66-4f2f-bc4f-24dbb99b43c7","order_by":6,"name":"Haijiang Zhou","email":"","orcid":"","institution":"Beijing Chao-Yang Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Haijiang","middleName":"","lastName":"Zhou","suffix":""},{"id":281895904,"identity":"ef74d437-5f59-431a-b032-8735eb81a7e1","order_by":7,"name":"Xue Mei","email":"","orcid":"","institution":"Beijing Chao-Yang Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xue","middleName":"","lastName":"Mei","suffix":""},{"id":281895905,"identity":"7a661ea0-b509-480c-ab5f-312320e3eb67","order_by":8,"name":"Shubin Guo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYDACCQY2hgQGCR774w0MDIwNxGuxkWM4cwCqhY0YLQwMacYMNxKI1CI/u8fswcMdhxMbZ74xfPBzB0MevzwB1xncOWNukHjmcGKzdI6xYe8ZhmLJNgK2GEjkmEkkth1ObJMGMnjbGBI3HCPksBlQLT2SZ8x//gVq2U9IC8MNsJY0YwkJHjNmsC2EvG9wI63cILHNRs6AJ61YWrZNInHGsQRCDkve9vBnmwSPAfvhjR/fttkk9jcfIOQyOOAwYABFEymA/QFJykfBKBgFo2DkAAADn0RjVQ24nAAAAABJRU5ErkJggg==","orcid":"","institution":"Beijing Chao-Yang Hospital, Capital Medical University","correspondingAuthor":true,"prefix":"","firstName":"Shubin","middleName":"","lastName":"Guo","suffix":""}],"badges":[],"createdAt":"2024-03-04 08:17:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4011079/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4011079/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53266163,"identity":"17ff803e-04fa-4d81-b90c-a583fb3f21ef","added_by":"auto","created_at":"2024-03-22 15:38:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":257962,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of patient enrollment.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4011079/v1/da2f25ba611ffb82f0c32da2.png"},{"id":53266160,"identity":"2b65c41e-b32a-4a3f-8262-398112ee36be","added_by":"auto","created_at":"2024-03-22 15:38:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":36429,"visible":true,"origin":"","legend":"\u003cp\u003eTest statistics at the upper and lower bounds\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4011079/v1/0c942915c0d406a4eae00b0e.png"},{"id":53266162,"identity":"104b7368-72b3-4790-8942-5fe83d515e92","added_by":"auto","created_at":"2024-03-22 15:38:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":38604,"visible":true,"origin":"","legend":"\u003cp\u003eSpending function plot\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4011079/v1/561cd8f6b25d4abd4f5f0adc.png"},{"id":53266161,"identity":"2f4905a6-db92-4415-9ca4-5e068d20f501","added_by":"auto","created_at":"2024-03-22 15:38:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":30841,"visible":true,"origin":"","legend":"\u003cp\u003eExpected sample size by underlying treatment difference\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4011079/v1/3e8646b41a756df77dcf9a4c.png"},{"id":63427802,"identity":"230bb9b9-156e-4c8f-9f31-9bc0b71d6408","added_by":"auto","created_at":"2024-08-28 04:22:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":810881,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4011079/v1/51972134-34fa-4113-929a-325b887b4c2c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy and Safety of Anisodamine Hydrobromide Combined with Low-molecular-weight Heparin for the Treatment of Sepsis Patients: Study Protocol for a Multicenter Randomized Controlled Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAfter a 15-year hiatus, the introduction of Sepsis-3 in 2016 marked a significant milestone. Sepsis is a life-threatening condition characterized by organ dysfunction resulting from a dysregulated host response to infection, surpassing the lethality of a mere infection and necessitating urgent recognition [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Within the spectrum of sepsis cases, septic shock represents a subset with notably higher mortality rates. Both severe sepsis and septic shock are leading causes of mortality among patients admitted to the intensive care unit (ICU) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Sepsis remains the predominant cause of death overall, contributing to one-third to one-half of all hospital deaths [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA meta-analysis of data collected prior to 2022 indicated that the estimated combined in-hospital mortality rates for hospital-wide sepsis and ICU sepsis in China were 26% (95% CI: 16\u0026ndash;36%) and 40% (95% CI: 34\u0026ndash;47%), respectively [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Another meta-analysis covering the period from 2009 to 2019 across Europe, North America, and Australia revealed a 30-day mortality rate of 24.39% in patients with sepsis, with the 30-day mortality for septic shock patients reaching 34.73% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A random-effects meta-analysis consolidating global data from 2015 to 2019 estimated a hospital-wide inpatient mortality rate of 26.7% and an inpatient mortality rate of 41.9% for ICU patients with sepsis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the Surviving Sepsis Campaign, the treatment of sepsis and septic shock encompasses a triad involving hemodynamic resuscitation with crystalloids, vasopressor infusion, and the administration of antimicrobials within the first hour of diagnosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In recent years, numerous treatment strategies have been explored to alleviate the disease burden associated with septic shock. For example, combination therapy involving hydrocortisone, vitamin C, and thiamine has been shown to increase the duration of vasopressor-free survival in patients with septic shock [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Additionally, the use of anisodamine has been explored for its ability to reduce hospital mortality [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], while the coadministration of iloprost and eptifibatide has been studied for its ability to attenuate endothelial injury and platelet consumption and improve the Sequential Organ Failure Assessment (SOFA) score in patients with septic shock [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Levocarnitine has been investigated for its potential to reduce cumulative organ failure within 48 hours and decrease 28-day mortality in septic shock patients [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, progress in the foundational scientific knowledge of sepsis has not been commensurate with the introduction of new sepsis medications. A more accurate assessment of this situation would be that many new drugs have been developed, but none have demonstrated reproducible benefits to patients in clinical trials.\u003c/p\u003e \u003cp\u003eAniHBr is derived from the root of the plant Scopolia tangutica Maxim. in China and has been produced on a large scale since 2016. AniHBr acts as an M-choline receptor antagonist and is commonly used as a peripheral anticholinergic drug in clinical practice due to its minimal central side effects. In traditional Chinese medicine, AniHBr is utilized to treat various diseases and has effects such as relieving vasospasm (particularly in microvessels), improving microcirculation, relaxing smooth muscle, suppressing glandular secretion, inhibiting shock, dilating pupils, and providing analgesia [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnisodamine (654-2) and AniHBr (654-1) are both traditional Chinese medicines that are M receptor antagonists. In 2021, a randomized controlled trial revealed no evidence that anisodamine (654-2) can reduce hospital mortality among critically ill adults with septic shock treated in the intensive care unit [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Previous animal experiments have demonstrated that AniHBr can significantly reduce the serum levels of creatine kinase and lactic acid in rats with lipopolysaccharide-induced septic shock while also improving hemodynamics [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. AniHBr, a traditional Chinese medicine, was shown in early studies by our research team to be a potentially crucial adjunctive medication in routine treatment. It may reduce the 28-day mortality, 7-day mortality, and hospital mortality rates in patients with septic shock, along with lowering lactate levels [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, there is still a lack of conclusive evidence from well-designed clinical trials supporting its efficacy in the treatment of sepsis.\u003c/p\u003e \u003cp\u003eWith a deepening understanding of the relationship between disseminated intravascular coagulation (DIC) and sepsis, the use of low-molecular-weight heparin (LMWH) in the treatment of sepsis and septic shock has gained increasing attention, and its effectiveness is increasingly recognized. Recent studies have indicated that early administration of LMWH can significantly inhibit thrombocytopenia and improve tissue perfusion, and two systematic reviews have highlighted the potential benefits of low-molecular-weight heparin for survival in sepsis patients without a major bleeding risk [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aimed to investigate the addition of AniHBr combined with low-molecular-weight heparin to the conventional treatment of sepsis patients, providing a new approach for sepsis treatment and potentially reducing mortality rates associated with this condition. However, conclusive evidence from well-designed clinical trials supporting its efficacy is lacking.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy design and setting\u003c/h2\u003e\n \u003cp\u003eThis was a prospective, multicenter, randomized study conducted at seven participating hospitals in Beijing, China. Patients with sepsis will be enrolled between December 2023 and February 2025. The investigators at each participating center will screen potential patients with sepsis to determine their eligibility for the study. Prior to commencing the study, the study underwent review and received approval from the institutional review board of Beijing Chaoyang Hospital, which is affiliated with Capital Medical University (Approval No.2022-620-1), as well as the ethics committee of each participating center. Informed consent will be obtained from all participants or their next of kin before their inclusion in the study.\u003c/p\u003e\n \u003cp\u003eThe study was registered on the Clinical Trials website. gov (registration no. NCT05634057).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e\n \u003cp\u003eThe inclusion criteria for this study were as follows:\u003c/p\u003e\n \u003cp\u003e1) Patients must be over 18 years old.\u003c/p\u003e\n \u003cp\u003e2) Patients must have a diagnosis of sepsis, as defined by The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003e3) Patients must be willing to provide informed consent by signing the consent form.\u003c/p\u003e\n \u003cp\u003eThe exclusion criteria for this study were as follows:\u003c/p\u003e\n \u003cp\u003e1) Patients who were expected to die within 24 hours after enrollment.\u003c/p\u003e\n \u003cp\u003e2) Contraindications to low-molecular-weight heparin and scopolamine butylbromide drugs.\u003c/p\u003e\n \u003cp\u003e3) Thrombotic disease requiring treatment with low-molecular-weight heparin.\u003c/p\u003e\n \u003cp\u003e4) Patients with terminal-stage malignancies, severe immunodeficiency, immunosuppression, severe liver or kidney dysfunction (defined as liver or kidney SOFA score\u0026thinsp;\u0026ge;\u0026thinsp;3 points), etc.\u003c/p\u003e\n \u003cp\u003e5) Pregnant or lactating women.\u003c/p\u003e\n \u003cp\u003e6) Patients participating in other clinical trials.\u003c/p\u003e\n \u003cp\u003eThe methods of recruiting subjects involved utilizing hospital records, briefing family members and/or patients about the study by doctors and researchers, and allowing family members and/or patients to make a decision regarding participation in the trial.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnostic criteria for sepsis (including septic shock)\u003c/strong\u003e [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e1. Patient with suspected infection. \u003cspan\u003e\n \u003cp\u003e2. qSOFA\u0026thinsp;\u0026ge;\u0026thinsp;2.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e3. Assessment of evidence of organ dysfunction\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e4. SOFA\u0026thinsp;\u0026ge;\u0026thinsp;2.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e5. Despite adequate fluid resuscitation, vasopressors are required to maintain a MAP\u0026thinsp;\u0026ge;\u0026thinsp;65 cm Hg and a serum lactate level\u0026thinsp;\u0026gt;\u0026thinsp;2 mmol/L.\u003c/p\u003e\n \u003c/span\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eIntervention\u003c/h2\u003e\n \u003cp\u003eIn the control group, the initial treatment strategy followed the recommendations outlined in the Surviving Sepsis Campaign (SSC) guidelines [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e] within the first 24 hours after the diagnosis of sepsis. This strategy included two variables:\u003c/p\u003e1. The following resuscitation measures were implemented within the first 6 hours of septic shock:\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eMeasurement of lactate levels\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eCollection of cultures prior to initiating antibiotic treatment\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eAdministration of broad-spectrum antibiotics\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eAdministration of fluids and vasopressors to achieve a mean arterial pressure (MAP)\u0026thinsp;\u0026gt;\u0026thinsp;65 mmHg\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\u003cspan\u003e\n \u003cp\u003e2. All treatment measures were implemented within 24 hours, including the following:\u003c/p\u003e\n \u003c/span\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eConsideration of low-dose corticosteroids in patients with septic shock\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eBlood glucose control\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThe plateau pressure was monitored and controlled to ensure protective mechanical ventilation.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eIn the intervention group, a combination therapy approach was employed, which included Ani HBr injection, low-molecular-weight heparin, and traditional treatment as per the SSC guidelines. The intervention protocol was as follows:\u003c/p\u003e\n \u003cp\u003eAni HBr Injection:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eThe dosage of Ani HBr injected was 2.0 mg/(kg*d), which was administered via a micropump at a constant rate continuously for 3 days.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eLow-molecular-weight heparin:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eThe dosage range for low-molecular-weight heparin is limited to 3000\u0026ndash;6000 U, and heparin is administered subcutaneously once daily for 3 days.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy endpoint\u003c/h2\u003e\n \u003cp\u003eThe primary endpoint of this study was 28-day mortality, which was assessed by determining the mortality rate of patients over 28 days. The patients will be followed up for 28 days. In the event that patients are discharged earlier than 28 days, their survival time will be recorded as of day 28 after admission or diagnosis with septic shock.\u003c/p\u003e\n \u003cp\u003eThe secondary endpoints of the study included the following:\u003c/p\u003e\n \u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eLactate clearance rate: The rate of lactate clearance will be evaluated at specific time points, namely, 6 hours, 24 hours, and 72 hours after admission. This will involve measuring the reduction in lactate levels, which serve as an indicator of the patient\u0026apos;s response to treatment.\u003c/li\u003e\n \u003cli\u003eLength of stay in the ICU and hospital: The duration of ICU and hospital stay will be recorded, providing insights into the patient\u0026apos;s healthcare resource utilization and recovery trajectory.\u003c/li\u003e\n \u003cli\u003eOrgan failure-free days: Organ failure will be evaluated using the Sequential Organ Failure Assessment (SOFA) score. The number of organ failure-free days was calculated, indicating the duration during which the patient did not experience organ failure.\u003c/li\u003e\n \u003cli\u003eNumber of days with vasopressor use within 28 days.\u003c/li\u003e\n \u003cli\u003eSeptic shock conversion rate.\u003c/li\u003e\n \u003cli\u003eThe 28-day mortality rate of septic shock patients.\u003c/li\u003e\n \u003cli\u003eThe 72-hour sublingual microcirculation.\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eThese secondary study endpoints aim to provide additional information on the effectiveness of the intervention and its impact on various clinical outcomes related to sepsis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eAdverse events\u003c/h2\u003e\n \u003cp\u003ePatient safety will be a paramount consideration throughout the study, and measures will be in place to monitor and address any potential adverse events. At each study visit, the safety of the patients will be carefully assessed and monitored.\u003c/p\u003e\n \u003cp\u003eAdverse events [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] that are closely monitored include but are not limited to:\u003c/p\u003e\n \u003cp\u003e\u003cspan\u003e1. New-onset psychosis: Any occurrence of new psychiatric symptoms or changes in mental status will be thoroughly evaluated and reported.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e2. Urinary retention: Instances of urinary retention, where the patient experiences difficulty or inability to empty the bladder, will be monitored and documented.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e3. Significant hypotension: Patients with severe low blood pressure will be closely monitored and managed appropriately.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e4. Tachycardia: Instances of rapid heart rate exceeding the normal range will be monitored and documented.\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eIn the event of any adverse event, patients will be promptly informed and instructed to discontinue their participation in the study. Patient safety is of utmost importance, and the study protocol includes provisions to ensure that the well-being and safety of the patients are prioritized. This includes closely monitoring adverse events and taking appropriate actions to mitigate any risks or harm to the patients involved in the study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eData collection\u003c/h2\u003e\n \u003cp\u003eIn this study, data collection will be conducted by research coordinators using paper data forms. The case report form (CRF) will be written in Chinese to facilitate effective communication among investigators. To ensure accuracy, the correctness of the original CRFs will be carefully verified.\u003c/p\u003e\n \u003cp\u003eSubsequently, a database will be established using an electronic data capture (EDC) system. The data will be entered into the database by two trained data entry clerks independently. Following the initial data entry, a process of double entry verification will be conducted to compare the entries and identify any inconsistencies or errors.\u003c/p\u003e\n \u003cp\u003eIn case of any inconsistencies or discrepancies found within the database, a thorough item-by-item review of the original record table will be performed for proofreading and correction. Once all the necessary corrections and verifications are completed, the database will be locked to prevent further changes.\u003c/p\u003e\n \u003cp\u003eThis data collection and entry process ensures the integrity and accuracy of the collected data, reducing the chances of errors or discrepancies during the study analysis phase.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eGroup sequential analysis and sample size estimation\u003c/h2\u003e\n \u003cp\u003eThis study follows a superiority trial design and employs the group sequential method to estimate the required sample size. Considering the cost associated with Ani HBr and the potential effectiveness of interim analyses, the trial has provisions to stop early under certain circumstances. The reasons for early termination of the clinical trial may include the following:\u003c/p\u003e\n \u003cp\u003e\u003cspan\u003e1. Serious toxicity or adverse events: If there are significant safety concerns or unexpected severe adverse events associated with the treatment, the trial may be stopped early to ensure patient safety.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e2. Established benefit: If interim analyses indicate a clear and statistically significant benefit of the treatment being investigated, it may be considered unethical to continue the trial, and it may be stopped early to provide the treatment to a larger population.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e3. Design or logistical difficulties that are too serious to fix: In situations where there are significant design or logistical challenges that cannot be resolved without compromising the integrity or validity of the trial, the study may be stopped early.\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eTo facilitate the design of group sequential trials, the R package \u0026quot;gsDesign\u0026quot; will be utilized. This package allows for the implementation of group sequential analyses in which promising treatments can be selected at various interim analyses. The group sequential method enables efficient monitoring of treatment effects and provides the flexibility to potentially stop the trial early if specific criteria are met.\u003c/p\u003e\n \u003cp\u003eBy incorporating the group sequential method and the ability to perform interim analyses, this trial aims to optimize the use of resources, reduce costs, and efficiently evaluate the effectiveness and safety of the treatment under investigation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e\u003cstrong\u003eParameters\u003c/strong\u003e:\u003c/h2\u003e\n \u003cp\u003eBased on the information provided, it appears that a group sequential design will be implemented with lower bound spending under the null hypothesis, three-stage analyses, 80% power, and a 2.5% (1-sided) type I error rate. The following details were specified:\u003c/p\u003e\n \u003cp\u003e\u003cspan\u003e1. The mortality rate in the control group is assumed to be 29%, and the new intervention is expected to reduce the mortality rate by 9%.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e2. Fixed sample size: The sample size for the fixed design with no interim was 782, which was calculated by PASS21.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e3. Timing of interim analyses: Interim analyses will be conducted at three equally spaced accrual sample sizes: 266, 531, and 796 (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e4. Spending functions: The Hwang-Shih-DeCani [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e] spending function will be used, with lower bound spending with gamma=-2 and alpha spending with gamma=-4.\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eThe expected behavior of the trial and the sample size calculations are summarized as follows:\u003c/p\u003e\n \u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eMaximum total sample size: The maximum total sample size for the trial was 796.\u003c/li\u003e\n \u003cli\u003eAlpha spending: Table 2 provides the alpha spending function, which indicates the cumulative type I error rate at each interim analysis.\u003c/li\u003e\n \u003cli\u003eBeta spending: Table 3 presents the beta spending function, which indicates the cumulative type II error rate at each interim analysis.\u003c/li\u003e\n \u003cli\u003eBoundary crossing probabilities: Figure 2 illustrates the upper boundary crossing probabilities. If any interim analysis crosses the upper boundary, the trial will be stopped. However, the trial will continue if any analysis crosses the lower boundary.\u003c/li\u003e\n \u003cli\u003eSpending function plot: Figure 3 displays the spending function plot for alpha and beta, derived using the Hwang-Shih-DeCani spending function.\u003c/li\u003e\n \u003cli\u003eExpected sample size: Figure 4 shows the expected sample sizes for different underlying risk factors. At the assumed risk difference of 0.1, the expected sample size is estimated to be 661, which is smaller than the fixed sample size of 782.\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eBy implementing the group sequential design with the specified parameters, the trial aims to achieve more efficient sample size utilization while maintaining sufficient statistical power to evaluate the effectiveness of the new intervention.\u0026nbsp;\u003c/p\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUpper and lower bounds expressed at different scales\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e---------Lower bounds---------\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e--------- Upper bounds---------\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnalysis*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en.I**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZ****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNominal p*****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpend+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNominal p\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpend++\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.3393\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6786\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e531\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4082\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2817\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e796\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9772\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0228\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0188\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0250\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003e*3 equally spaced analyses.\u003c/p\u003e\n \u003cp\u003e**Average sample number/expected sample size is computed using n.I. at each analysis times the probability of crossing a boundary at that analysis. If no boundary is crossed at any analysis, this is considered stopping at the final analysis.\u003c/p\u003e\n \u003cp\u003e***Expected sample size for each analysis.\u003c/p\u003e\n \u003cp\u003e**** Test statistics of each analysis.\u003c/p\u003e\n \u003cp\u003e*****P value of each analysis.\u003c/p\u003e\n \u003cp\u003e++\u0026beta;-spending of each analysis. ++\u0026alpha;spending of each analysis.\u003c/p\u003e\n \u003cdiv\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUpper boundary (power or Type I Error)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAnalysis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026delta;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eE{N}\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e642.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0840\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.3284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.3876\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e661.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026delta; represents the risk difference. Upper boundary crossing probabilities and assume that any cross stops the trial.\u003c/p\u003e\n \u003cdiv\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLower boundary (futility or Type II Error)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAnalysis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026delta;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2817\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.975\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1919\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026delta; represents the risk difference. We set lower bound spending under the null hypothesis with a nonbinding lower bound and assume that any cross stops the trial.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eRandomization\u003c/h2\u003e\n \u003cp\u003eIn this study, blocked randomization was employed to allocate subjects to either the combination therapy group or the control group. The randomization was performed at a 1:1 ratio using blocks of sizes 2,4,6,8 to 796 subjects.\u003c/p\u003e\n \u003cp\u003eTo ensure random assignment concealment, a web-based central random system was utilized. The person in charge of each center accessed the network system and entered the basic information of the subjects who met the inclusion and exclusion criteria. The central random system automatically assigned a random number to each subject. Once a random number was assigned, it could not be assigned to another subject. It is important to note that subjects who failed to complete the entire study could not be included.\u003c/p\u003e\n \u003cp\u003eRandom sequence allocation and allocation hiding were implemented through the use of a central stochastic system. This ensured that the allocation process was unbiased and concealed from the investigators involved in the study.\u003c/p\u003e\n \u003cp\u003eThis study is an open-label trial, meaning that both the researchers and participants are aware of the treatment assignment. The protocol details can be found in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, which provides a summary of the study design and procedures.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical analysis\u003c/h2\u003e\n \u003cp\u003eThe primary and secondary efficacy analyses in this study were conducted using the intention-to-treat (ITT) analysis set. The analysis will involve baseline variables, which include both measurement data and count data.\u003c/p\u003e\n \u003cp\u003eThe measurement data are presented as the mean (standard deviation, SD) or number (percent), while the count data are expressed as the median and interquartile range.\u003c/p\u003e\n \u003cp\u003eTo compare the means of continuous random variables between the two groups, t tests will be utilized. The proportions test will be employed for dichotomous response variables, and the log-rank test will be used for censored survival data. For the binary variable of mortality, a chi-square test will be used for the comparison.\u003c/p\u003e\n \u003cp\u003eA mixed linear model will be utilized to assess the effect of treatment on outcomes and to perform repeated-measures analysis of variance. The statistical tests will be two-sided, and a p value less than 0.05 will be considered to indicate statistical significance.\u003c/p\u003e\n \u003cp\u003eAll the statistical analyses will be conducted using R software, specifically version 4.3.1. R is a widely used statistical programming language that provides a range of statistical functions and packages for data analysis.\u003c/p\u003e\n \u003cp\u003eBy employing appropriate statistical methods and software, this study aimed to analyze the data accurately and determine the significance of the treatment effect on the evaluated outcomes.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSepsis often disrupts the systemic distribution of blood flow to organ systems through vasodilation and disturbances in microcirculation. In the context of septic shock, endothelial dysfunction, glycocalyx degradation, alterations in blood cell rheology (reduced red blood cell deformability), and an imbalance in levels of vasoactive substances can lead to changes in microcirculation. This may alter the matching of blood flow to tissue demands. Therefore, optimizing microcirculation should be prioritized during the resuscitation process. The authors emphasize that while early-stage resuscitation and the restoration of macrocirculatory variables (cardiac output, mean arterial pressure, etc.) may improve microcirculatory flow, monitoring microcirculation and implementing interventions tailored to microcirculatory resuscitation are essential to prevent harm to microcirculation during interventions in macrocirculation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCoagulation activation is one of the mechanisms triggered by the innate immune system to recognize invading pathogens, aiding in their clearance. During sepsis, increased tissue factor expression, downregulation of natural anticoagulant pathways, and inadequate fibrinolysis contribute to increased thrombin generation and clot formation. Dysregulated coagulation activation may lead to microvascular thrombosis and hypoxia, causing tissue damage in sepsis. This, in turn, can result in disseminated intravascular coagulation, potentially causing organ dysfunction if severe enough [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The key to treating sepsis-induced coagulopathy is the rapid and timely treatment of underlying infections. Strategies widely studied aim to suppress prothrombotic effects, with heparin and its derivatives commonly used for preventing deep vein thrombosis in sepsis treatment [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo meta-analyses have indicated a potential association between heparin use and reduced mortality in sepsis patients [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Yiting Tang et al. suggested that heparin prevents the caspase-11-dependent immune response and lethality in sepsis, independent of its anticoagulant properties. They proposed the therapeutic use of modified heparin or low-dose heparin, which lacks anticoagulant activity but can block HMGB1-mediated intracellular LPS delivery and heparanase-mediated glycocalyx degradation. This approach might offer a strategy to minimize bleeding risks [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, Iba T et al. suggested that heparin, by activating anticoagulant proteins and inhibiting coagulation, lacks sufficient confirmatory data for its use. Therefore, the potential risk of heparin-induced thrombocytopenia (HIT) should be carefully considered when assessing the risk-benefit balance [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e654-1, which is derived from the roots of Scopolia tangutica Maxim. in China, has been produced on a large scale since 2016. Acting as an M-choline receptor antagonist, it is commonly used as a peripheral anticholinergic drug in clinical practice due to minimal central side effects. In traditional Chinese medicine, 654-1 is used to treat various diseases, as it relieves vasospasm, improves microcirculation, relaxes smooth muscle, suppresses glandular secretion, has anti-shock properties, dilates the pupils, and provides analgesia [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Animal experiments demonstrated that 654-1 could significantly reduce the serum levels of creatine kinase and lactic acid in rats with lipopolysaccharide-induced septic shock while improving hemodynamics [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a previous randomized controlled trial (RCT), 654-1 was shown to be a potentially important adjunctive therapy in conventional treatment, reducing the 28-day mortality, 7-day mortality, and hospital mortality rates of septic shock patients, as well as lowering lactate levels. However, the results primarily indicated potential benefits for patients with severe disease severity [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile the effective dosage has been identified through preliminary exploration, this trial expands the study population and introduces an innovative combination of two drugs. The response of patients to this combination remains unknown, necessitating an adaptive design to promptly adjust drug timing, dosage, and sample size.\u003c/p\u003e \u003cp\u003eThe goal of adaptive trial design is to identify intervention measures with therapeutic effects more quickly than traditional trial designs. It focuses on patient populations where the drug is effective. An ideal adaptive trial design could lead to the early cessation of ineffective drugs and the simultaneous assessment of different dosing regimens of potentially effective drugs [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCompared to traditional clinical trial designs with predefined features that remain constant throughout the trial, adaptive design models evolve key trial features during the trial based on predefined rules [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. One crucial evolving trial feature is the randomized probability of assigning new subjects to available treatment groups. For example, subjects may be prioritized for assignment to a treatment group that appears to perform better [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], or similarly, subjects may be prioritized for assignment to doses that seem to increasingly offer clinically relevant benefits with acceptable side effects [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. These adjustments enhance the efficiency of clinical trials, provide more opportunities for successful learning goals, and offer a better understanding of treatment effects, thereby contributing to more effective designs for subsequent studies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol was reviewed and approved by the Institutional Review Board and Medical Ethics Committee of Beijing Chao-Yang Hospital (Ethical approval number: 2022-ke-620-1) and each participating center. Written informed consents to participate in the study were obtained from participants or their legal guardians.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by the Capital Research on Special Clinical Application (No. Z211100002921061).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe raw/processed data required to reproduce these findings cannot beshared at this time as the data also forms part of an ongoing study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSinger M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Jama. 2016;315:801-10.\u003c/li\u003e\n\u003cli\u003eGenga KR, Russell JA, et al. Update of Sepsis in the Intensive Care Unit. J Innate Immun. 2017;9(5):441-455.\u003c/li\u003e\n\u003cli\u003eCohen J, Vincent JL, Adhikari NK, Machado FR, Angus DC, Calandra T, Jaton K, Giulieri S, Delaloye J, Opal S, Tracey K, van der Poll T, Pelfrene E. Sepsis: a roadmap for future research. Lancet Infect Dis. 2015 May;15(5):581-614.\u003c/li\u003e\n\u003cli\u003eLei S, Li X, Zhao H, Xie Y, Li J. Prevalence of sepsis among adults in China: A systematic review and meta-analysis. Front Public Health. 2022 Oct 11;10:977094.\u003c/li\u003e\n\u003cli\u003eBauer M, Gerlach H, Vogelmann T, Preissing F, Stiefel J, Adam D. Mortality in sepsis and septic shock in Europe, North America and Australia between 2009 and 2019- results from a systematic review and meta-analysis. Crit Care. 2020 May 19;24(1):239.\u003c/li\u003e\n\u003cli\u003eFleischmann-Struzek C, Mellhammar L, Rose N, Cassini A, Rudd KE, Schlattmann P, Allegranzi B, Reinhart K. Incidence and mortality of hospital- and ICU-treated sepsis: results from an updated and expanded systematic review and meta-analysis. Intensive Care Med. 2020 Aug;46(8):1552-1562.\u003c/li\u003e\n\u003cli\u003eEvans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247.\u003c/li\u003e\n\u003cli\u003eFujii T, Luethi N, Young PJ, et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial. JAMA. 2020 Feb 4;323(5):423-431. doi: 10.1001/jama.2019.22176. PMID: 31950979; PMCID: PMC7029761.\u003c/li\u003e\n\u003cli\u003eLyu QQ, Zheng RQ, Chen QH, et al. Early administration of hydrocortisone, vitamin C, and thiamine in adult patients with septic shock: a randomized controlled clinical trial. Crit Care. 2022 Sep 28;26(1):295.\u003c/li\u003e\n\u003cli\u003eHwang SY, Ryoo SM, Park JE, et al. Combination therapy of vitamin C and thiamine for septic shock: a multicenter, double-blinded randomized, controlled study. Intensive Care Med. 2020 Nov;46(11):2015-2025.\u003c/li\u003e\n\u003cli\u003eYu Y, Zhu C, Zhang Z, et al. Effectiveness of anisodamine for the treatment of critically ill patients with septic shock: a multicenter randomized controlled trial. Crit Care. 2021 Sep 27;25(1):349.\u003c/li\u003e\n\u003cli\u003eBerthelsen RE, Ostrowski SR, Bestle MH, Johansson PI. Coadministration of iloprost and eptifibatide in septic shock (CO-ILEPSS)-a randomized, controlled, double-blind investigator-initiated trial investigating safety and efficacy. Crit Care. 2019 Sep 5;23(1):301.\u003c/li\u003e\n\u003cli\u003eJones AE, Puskarich MA, Shapiro NI, et al. Effect of Levocarnitine vs Placebo as an Adjunctive Treatment for Septic Shock: The Rapid Administration of Carnitine in Sepsis (RACE) Randomized Clinical Trial. JAMA Netw Open. 2018 Dec 7;1(8):e186076.\u003c/li\u003e\n\u003cli\u003eEisenkraft A, Falk A. Possible role for anisodamine in organophosphate poisoning. Br J Pharmacol. 2016 Jun;173(11):1719-27.\u003c/li\u003e\n\u003cli\u003eWan F, Du X, Liu H, He X, Zeng Y. Protective effect of AniHBr on lipopolysaccharide-induced acute kidney injury. Biosci Rep. 2020 Jul 31;40(7):BSR20201812.\u003c/li\u003e\n\u003cli\u003eZhang F, Mei X, Zhou P, Tian YP, Liu JX, Dong X, Yuan DS, Lin ZF, Zhang L, Lin JH, Li AJ, Deng X, Chen MZ, Yuan SY, Zha JJ, Shi B, Lin ZH, Guo SB. Anisodamine hydrobromide in the treatment of critically ill patients with septic shock: a multicenter randomized controlled trial. Ann Med. 2023;55(2):2264318.\u003c/li\u003e\n\u003cli\u003eZarychanski R, Abou-Setta AM, Kanji S, Turgeon AF, Kumar A, Houston DS, et al. The efficacy and safety of low-molecular-weight heparin in patients with sepsis: a systematic review and metaanalysis. Critical care medicine. 2015;43:511-8.\u003c/li\u003e\n\u003cli\u003eFu S, Yu S, Wang L, Ma X, Li X. Unfractionated low-molecular-weight heparin improves the clinical efficacy in adult sepsis patients: a systematic review and meta-analysis. BMC anesthesiology. 2022;22:28.\u003c/li\u003e\n\u003cli\u003eHonore PM, Redant S, Preseau T, Cismas BV, Kaefer K, Barreto Gutierrez L, Anane S, Attou R, Gallerani A, De Bels D. Anisodamine microcirulatory effects in septic shock: be aware of cardiac side effects. Crit Care. 2021 Dec 16;25(1):433.\u003c/li\u003e\n\u003cli\u003eHwang IK, Shih WJ, De Cani JS. Group sequential designs using a family of type I error probability spending functions. Stat Med 1990;9:1439-45.\u003c/li\u003e\n\u003cli\u003eCecconi M, Evans L, Levy M, Rhodes A. Sepsis and septic shock. Lancet. 2018 Jul 7;392(10141):75-87.\u003c/li\u003e\n\u003cli\u003eKhanna AK, Karamchandani K. Macrocirculation and Microcirculation: The \u0026quot;Batman and Superman\u0026quot; Story of Critical Care Resuscitation. Anesth Analg. 2021 Jan;132(1):280-283.\u003c/li\u003e\n\u003cli\u003eFiusa MM, Carvalho-Filho MA, Annichino-Bizzacchi JM, De Paula EV. Causes and consequences of coagulation activation in sepsis: an evolutionary medicine perspective. BMC Med. 2015 May 6;13:105.\u003c/li\u003e\n\u003cli\u003eTaylor FB Jr, Toh CH, Hoots WK, Wada H, Levi M; Scientific Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Hemostasis (ISTH): . Toward definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Hemost . 2001; 86:1327\u0026ndash;30\u003c/li\u003e\n\u003cli\u003eMiranda M, Balarini M, Caixeta D, Bouskela E. Microcirculatory dysfunction in sepsis: pathophysiology, clinical monitoring, and potential therapies. Am J Physiol Heart Circ Physiol. 2016 Jul 1;311(1):H24-35.\u003c/li\u003e\n\u003cli\u003eZarychanski R, Abou-Setta AM, Kanji S, Turgeon AF, Kumar A, Houston DS, Rimmer E, Houston BL, McIntyre L, Fox-Robichaud AE, H\u0026eacute;bert P, Cook DJ, Fergusson DA; Canadian Critical Care Trials Group. The efficacy and safety of heparin in patients with sepsis: a systematic review and metaanalysis. Crit Care Med. 2015 Mar;43(3):511-8.\u003c/li\u003e\n\u003cli\u003eWang C, Chi C, Guo L, Wang X, Guo L, Sun J, Sun B, Liu S, Chang X, Li E. Heparin therapy reduces 28-day mortality in adult severe sepsis patients: a systematic review and meta-analysis. Crit Care. 2014 Oct 16;18(5):563.\u003c/li\u003e\n\u003cli\u003eTang Y, Wang X, Li Z, He Z, Yang X, Cheng X, Peng Y, Xue Q, Bai Y, Zhang R, Zhao K, Liang F, Xiao X, Andersson U, Wang H, Billiar TR, Lu B. Heparin prevents caspase-11-dependent septic lethality independent of anticoagulant properties. Immunity. 2021 Mar 9;54(3):454-467.e6.\u003c/li\u003e\n\u003cli\u003eIba T, Levi M, Levy JH. Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation. Semin Thromb Hemost. 2020 Feb;46(1):89-95. doi: 10.1055/s-0039-1694995. Epub 2019 Aug 23. PMID: 31443111.\u003c/li\u003e\n\u003cli\u003eRui-Juan X, Hammerschmidt DE, Coppo PA, Jacob HS. Anisodamine Inhibits Thromboxane Synthesis, Granulocyte Aggregation, and Platelet Aggregation: A Possible Mechanism for Its Efficacy in Bacteremic Shock. JAMA. 1982;247(10):1458\u0026ndash;1460.\u003c/li\u003e\n\u003cli\u003eWan F, Du X, Liu H, He X, Zeng Y. Protective effect of anisodamine hydrobromide on lipopolysaccharide-induced acute kidney injury. Biosci Rep. 2020 Jul 31;40(7):BSR20201812.\u003c/li\u003e\n\u003cli\u003eLang T. Adaptive trial design: could we use this approach to improve clinical trials in the field of global health? Am J Trop Med Hyg. 2011 Dec;85(6):967-70.\u003c/li\u003e\n\u003cli\u003eOpal SM, Dellinger RP, Vincent JL, Masur H, Angus DC. The next generation of sepsis clinical trial designs: what is next after the demise of recombinant human activated protein C?*. Crit Care Med. 2014 Jul;42(7):1714-21.\u003c/li\u003e\n\u003cli\u003eHarhay MO, Wagner J, Ratcliffe SJ, Bronheim RS, Gopal A, Green S, Cooney E, Mikkelsen ME, Kerlin MP, Small DS, Halpern SD. Outcomes and statistical power in adult critical care randomized trials. Am J Respir Crit Care Med. 2014 Jun 15;189(12):1469-78.\u003c/li\u003e\n\u003cli\u003eLewis RJ, Viele K, Broglio K, Berry SM, Jones AE. An adaptive, phase II, dose-finding clinical trial design to evaluate L-carnitine in the treatment of septic shock based on efficacy and predictive probability of subsequent phase III success. Crit Care Med. 2013 Jul;41(7):1674-8.\u003c/li\u003e\n\u003cli\u003eDolgin E. Adaptive methods help drug sponsors find best treatment dose. Nat Med. 2014 Apr;20(4):321.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anisodamine hydrobromide, heparin, randomized controlled trial, sepsis","lastPublishedDoi":"10.21203/rs.3.rs-4011079/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4011079/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe objective of this study was to compare the effects of traditional treatment with those of anisodamine hydrobromide (Ani HBr) combined with low-molecular-weight heparin (LMWH) in the treatment of sepsis in hopes that this therapy will provide alternatives for the treatment of sepsis. This was a randomized, placebo-controlled, open-label, multicenter trial involving patients with sepsis recruited from seven emergency departments in Beijing, China. Patients diagnosed with sepsis will be randomly assigned to either the treatment or control group at a 1:1 ratio. The treatment group will receive Ani HBr combined with LMWH, while the control group will receive conventional treatment. A total of 782 sepsis patients will be recruited, and interim analysis will be conducted. The primary endpoint of the study was the 28-day mortality rate. The secondary endpoints included the lactate clearance rate at 6 hours, 24 hours, and 72 hours, the duration of ICU and hospital stay, the number of days without organ failure, the number of days with vasopressor use within 28 days, the septic shock conversion rate, the 28-day mortality rate of septic shock, and the 72-hour sublingual microcirculation. If the combination therapy of Ani HBr and LMWH demonstrates superior efficacy compared to conventional treatment, this study will provide valuable insights into the treatment of septic shock and potentially contribute to reducing the mortality rate associated with this condition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003eNCT05634057 (https://register.clinicaltrials.gov/).\u003c/p\u003e","manuscriptTitle":"Efficacy and Safety of Anisodamine Hydrobromide Combined with Low-molecular-weight Heparin for the Treatment of Sepsis Patients: Study Protocol for a Multicenter Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-22 15:38:24","doi":"10.21203/rs.3.rs-4011079/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fbd5d5fa-a8d2-465e-ad24-f33269c06140","owner":[],"postedDate":"March 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-28T04:14:42+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-22 15:38:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4011079","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4011079","identity":"rs-4011079","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}