Acute Cholecystitis Dr Swapnil Pawar
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Transfusion Thresholds in Intensive Care Dr Swapnil Pawar
VITAMINS Trial Dr Swapnil Pawar
Sir William Osler said that “except on a few occasions, the patient appears to die from the body’s response to infection rather than from the infection”
Sepsis is a major problem across the globe. Apart from the enormous financial costs of sepsis, the human toll of this disease is staggering and new interventions that limit the ravages of this disease are urgently required. Despite numerous RCTs, we still have not found the magic bullet to cure sepsis.
The role of Vitamin C in Sepsis has been debated a lot recently.
Multiple and overlapping effects of hydrocortisone, vitamin C, and thiamine in the setting of bacterial sepsis. Vitamin C and thiamine scavenge free radicals from superoxide (O2) and inhibit activation of xanthine oxidase and NADPH oxidase. Vitamin C protects the mitochondria from oxidative stress caused by increased leakage of electrons from the dysfunctional electron transport chain and recovers tetrahydrobiopterin (BH4) from dihydrobiopterin (BH2), restoring endothelial nitric oxide synthase (eNOS) activity and increasing eNO bioavailability. Vitamin C inhibits inducible NOS (iNOS) activation, preventing profuse iNO production and peroxynitrite (ONOO) generation. Vitamin C scavenges ONOO, preventing loosening of the tight junctions of the endothelium. Vitamin C and hydrocortisone decrease the activation of nuclear factor _B (NF-_B), thereby decreasing the release of proinflammatory mediators. They restore endothelial tight junctions and increase adrenergic receptor function. Thiamine increases the activity of pyruvate dehydrogenase and alpha ketoglutarate dehydrogenase. So there is strong case based on biological plausibility.
What’s known so far?
A previous randomized trial of 24 patients showed that high-dose IV vitamin C attenuated organ failure associated with sepsis in a dose-dependent manner.9 The combination of high-dose IV vitamin C and hydrocortisone together with thiamine was assessed in a single-center retrospective before-and-after study of 94 patients with severe sepsis or septic shock.13 The intervention was associated with shorter duration of vasopressor administration and lower hospital mortality.13 However, hydrocortisone alone has also consistently demonstrated efficacy in hastening the resolution of shock compared with placebo in 2 large multicentre double blind trials.14,15 It is unclear whether the combination of vitamin C, hydrocortisone, and thiamine is more effective than hydrocortisone alone.
Does treatment with vitamin C, hydrocortisone, and thiamine lead to a more rapid resolution of a septic shock compared with hydrocortisone alone?
Multicenter, unblinded, randomized controlled trial across 10 ICUs in Australia, New Zealand, and Brazil. Randomization was by computer-generated random numbers; permuted block sizes of 2, 4, and 6 were used in a 1:1 ratio, stratified by site.
Patients admitted with a primary diagnosis of septic shock were screened.
Documented or suspected infection with an increase SOFA score by at least 2 points
Lactate level higher than 2 mmol/L
On vasopressors for a minimum of 2 hours
Less than 18 years old
Patients who were imminently dying
Septic shock was diagnosed more than 24 hours ago
Study drugs otherwise indicated or contraindicated
786 screened à 570 excluded à 216 randomized
Intravenous vitamin C 1.5 g every 6 hours, hydrocortisone 50 mg every 6 hours, and thiamine 200 mg every 12 hours (all open label).
Intravenous hydrocortisone 50 mg intravenously, 6 h (open label). Thiamine administration was allowed based on physician discretion. Intravenous vitamin C was not allowed in the control arm.
Common to both arms
The study intervention was continued until vasopressors were stopped.
Cessation of vasopressors: All vasopressors off for 4 consecutive hours with a mean arterial pressure higher than 65 mm Hg or a MAP target set by the treating clinician.
Duration of time alive and free of vasopressors at day 7 (168 hours) after randomization. Patients had to be alive and free of vasopressors for at least 4 consecutive hours. Zero vasopressor hours if the patient died during the index episode of septic shock. If a patient remained off all vasopressors for 4 consecutive hours, then all of the remaining time until 7 was vasopressor-free, even if the patient died or had vasopressors restarted after weaning within the 7-day period.
The study was powered for 90% to detect a difference in vasopressor-free period of 25 h, based on a previous retrospective study with the use of this cocktail by Marik et al.
28-day cumulative vasopressor-free days
28-day cumulative mechanical ventilation-free days
28-day renal replacement therapy–free days
Change in SOFA score at day 3
ICU free-days at 28 days
Hospital length of stay
Vasopressor dose within the first 10 days: Not different
The maximum stage of acute kidney injury by the KDIGO criteria during the first 7 days after randomization: Not different
Recommencement of vasopressors by day 7 after vasopressor-free for 4 consecutive hours: 33.3%, vs control, 26.7%; P = .33 (not different)
One patient from each group died between the initial cessation of vasopressors and day 7.
Positive trial – as we know now there is no point in giving HAT therapy after 12 hours of ICU admission
Unable to change practices due to major limitations
Dr Swapnil Pawar February 3, 2020
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