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Shokri-Mashhadi N, Aliyari A, Hajhashemy Z, Saadat S, Rouhani MH. Is it time to reconsider the administration of thiamine alone or in combination with vitamin C in critically ill patients? A meta-analysis of clinical trial studies. J Intensive Care 2022; 10:8. [PMID: 35177121 PMCID: PMC8851730 DOI: 10.1186/s40560-022-00594-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 01/04/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Although the effect of thiamine alone or in combination with vitamin C has been studied in multiple trials (RCT and interventional studies), their results are inconsistent. This meta-analysis aimed to assess impact of thiamine administration alone, thiamine in combination with vitamin C, and co-administration of low-dose hydrocortisone, vitamin C and thiamine (HVT) on clinical outcomes in critically ill patients. METHODS AND MATERIALS After electronic searches on PubMed, Scopus, Cochrane Library, and Web of Science databases, initially 3367 papers were found, and 20 interventional studies were included in our analysis. We assessed the risk-difference between treatment and control (standard treatment) groups by pooling available data on ICU length of stay, number of ventilator free days, mortality, and changes in Sequential Organ Failure Assessment (SOFA) scores. RESULTS The results of present studies revealed no significant effect of thiamine in combination with vitamin C, and HVT on number of free days of ventilation. Thiamine alone supplementation was associated with high mortality percentage (WMD: 5.17%; 95% CI: 2.67, 7.67). Thiamine in combination with vitamin C had no significant impact on mortality rate. In contrast, HVT could decrease mortality rate (WMD: - 7.23%; 95% CI: - 10.31, - 4.16; I-square: 0.0%). There was no significant effect of thiamine alone, co-administration of thiamine and vitamin C, and HVT on ICU length of stay. The results of the meta-analysis showed that thiamine alone and HVT supplementation had no significant effect on SOFA score. Interestingly, co-supplementation of thiamine and vitamin C had a significant decreasing effect on SOFA score (WMD: - 0.73; 95% CI: - 1.29, - 0.17; I-square: 0.0%). CONCLUSION In contrast to HVT, thiamine supplementation alone was associated with increased mortality rate in ICU. However, co-supplementation of thiamine and vitamin C had a significant decreasing effect on SOFA score.
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Affiliation(s)
- Nafiseh Shokri-Mashhadi
- Food Security Research Center and Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Aliyari
- Food Security Research Center and Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Hajhashemy
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Saadat
- Faculty of Mathematics and Natural Sciences, Department of Computer Sciences, Heinrich Heine Universität, Düsseldorf, Germany
| | - Mohammad Hossein Rouhani
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
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152
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Gavrielatou E, Xourgia E, Xixi NA, Mantelou AG, Ischaki E, Kanavou A, Zervakis D, Routsi C, Kotanidou A, Siempos II. Effect of Vitamin C on Clinical Outcomes of Critically Ill Patients With COVID-19: An Observational Study and Subsequent Meta-Analysis. Front Med (Lausanne) 2022; 9:814587. [PMID: 35223911 PMCID: PMC8873176 DOI: 10.3389/fmed.2022.814587] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/19/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Whether vitamin C provides any benefit when administered in critically ill patients, including those with coronavirus disease (COVID-19), is controversial. We endeavored to estimate the effect of administration of vitamin C on clinical outcomes of critically ill patients with COVID-19 by performing an observational study and subsequent meta-analysis. METHODS Firstly, we conducted an observational study of critically ill patients with laboratory-confirmed COVID-19 who consecutively underwent invasive mechanical ventilation in an academic intensive care unit (ICU) during the second pandemic wave. We compared all-cause mortality of patients receiving vitamin C ("vitamin C" group) or not ("control" group) on top of standard-of-care. Subsequently, we systematically searched PubMed and CENTRAL for relevant studies, which reported on all-cause mortality (primary outcome) and/or morbidity of critically ill patients with COVID-19 receiving vitamin C or not treatment. Pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using a random effects model. The meta-analysis was registered with PROSPERO. RESULTS In the observational study, baseline characteristics were comparable between the two groups. Mortality was 20.0% (2/10) in the vitamin C group vs. 47.6% (49/103; p = 0.11) in the control group. Subsequently, the meta-analysis included 11 studies (6 observational; five randomized controlled trials) enrolling 1,807 critically ill patients with COVID-19. Mortality of patients receiving vitamin C on top of standard-of-care was not lower than patients receiving standard-of-care alone (25.8 vs. 34.7%; RR 0.85, 95% CI 0.57-1.26; p = 0.42). CONCLUSIONS After combining results of our observational cohort with those of relevant studies into a meta-analysis of data from 1,807 patients, we found that administration vitamin C as opposed to standard-of-care alone might not be associated with lower of mortality among critically ill patients with COVID-19. Additional evidence is anticipated from relevant large randomized controlled trials which are currently underway. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/, identifier: CRD42021276655.
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Affiliation(s)
- Evdokia Gavrielatou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Xourgia
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikoleta A. Xixi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Athina G. Mantelou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Ischaki
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Aggeliki Kanavou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Zervakis
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Christina Routsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ilias I. Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, United States
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153
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Ao G, Li J, Yuan Y, Wang Y, Nasr B, Bao M, Gao M, Qi X. Intravenous vitamin C use and risk of severity and mortality in COVID-19: A systematic review and meta-analysis. Nutr Clin Pract 2022; 37:274-281. [PMID: 35148440 PMCID: PMC9088481 DOI: 10.1002/ncp.10832] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The administration of intravenous vitamin C (IV-VC) in treating patients with coronavirus disease 2019 (COVID-19) is still highly controversial. There have been no previous studies on the effect of IV-VC on the severity and mortality of COVID-19. Hence, we conducted a systematic review and meta-analysis to compare the disease severity and mortality in patients with COVID-19 who promptly received IV-VC treatment vs those who did not. We performed a comprehensive systematic search of seven health science databases, including PubMed, Embase, Cochrane Library, MEDLINE, Web of Science, China National Knowledge Infrastructure, and Wanfang Data, up to June 23, 2021. We identified a total of seven related articles, which were included in this study. This meta-analysis showed that IV-VC treatment did not affect disease severity compared with placebo treatment or usual care (odds ratio [OR], 0.70; 95% CI, 0.45 to 1.07; P = 0.10). In addition, no statistically significant difference in mortality was observed between patients who received IV-VC treatment and those who did not (OR, 0.64; 95% CI, 0.41 to 1.00; P = 0.05). Moreover, the adjusted meta-analysis revealed that the use of IV-VC did not influence disease severity (OR, 0.67; 95% CI, 0.34 to 1.31; P = 0.242) or mortality (OR, 1.02; 95% CI, 0.75 to 1.40; P = 0.877) in comparison with a control group. The results of this meta-analysis demonstrated that short-term IV-VC treatment did not reduce the risk of severity and mortality in patients with COVID-19.
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Affiliation(s)
- Guangyu Ao
- Department of Nephrology, Chengdu First People's Hospital, Chengdu, Sichuan, China
| | - Jing Li
- Department of Nephrology, Chengdu First People's Hospital, Chengdu, Sichuan, China
| | - Yang Yuan
- Department of Minimally Invasive Surgery-Hepatobiliary and Pancreatic Surgery Thoracic Surgery, West China Fourth Hospital, Sichuan University, Sichuan, China
| | - Yushu Wang
- Chengdu West China Clinical Research Center CO, Ltd, Sichuan, China
| | - Basma Nasr
- Department of Cardiology, First Affiliated Hospital, Dalian Medical University, Dalian, Liaoning, China
| | - Mulong Bao
- Department of Intensive Care Unit, Chengdu First People's Hospital, Chengdu, Sichuan, China
| | - Ming Gao
- Department of Cardiology, Chengdu First People's Hospital, Chengdu, Sichuan, China
| | - Xin Qi
- Department of Neurology, The Affiliated Hospital of Southwest Jiaotong University & The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
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154
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Schmidt T, Kahn R, Kahn F. Ascorbic acid attenuates activation and cytokine production in sepsis-like monocytes. J Leukoc Biol 2022; 112:491-498. [PMID: 35141934 PMCID: PMC9543185 DOI: 10.1002/jlb.4ab0521-243r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 11/19/2021] [Accepted: 01/28/2022] [Indexed: 11/10/2022] Open
Abstract
Sepsis manifests due to the host's dysregulated immune response to infection. High-dose ascorbic acid (AA) has emerged as a potential treatment of sepsis, yet little is known regarding how AA influences the immune system in sepsis, such as monocytes. The objective of this study is to investigate the effects of high-dose AA on monocyte polarization and cytokine production in vitro. Monocytes isolated from healthy donors (n = 6) were polarized in vitro for 48 h using LPS or lipoteichoic acid (LTA). Polarization was confirmed by surface marker expression using flow cytometry. In parallel, monocytes from septic patients (n = 3) were analyzed for polarization markers as a comparison with the in vitro polarization. The effect of AA on monocyte polarization was then evaluated. Finally, monocytes were analyzed for cytokine production by intracellular staining. Both LPS and LTA induced polarization in healthy monocytes in vitro, with increased expression of both pro (M1) (CD40 and PDL1, p < 0.05) and anti-inflammatory (M2) (CD16 and CD163, p < 0.05) polarization markers. This pattern resembled that of monocytes from septic patients. Treatment with AA significantly inhibited surface expression of CD16 and CD163 (p < 0.05) in a dose-dependent manner. Finally, AA attenuated LPS- or LTA-induced cytokine production of IL-1ß, IL-6, IL-8, and TNF. In conclusion, AA attenuates proinflammatory cytokine production and diminishes up-regulation of CD16 and CD163, but not of CD40 and PDL-1 in LPS- or LTA-polarized monocytes. This study provides important insight into the effects of high-dose AA on monocytes and potential implications in sepsis.
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Affiliation(s)
- Tobias Schmidt
- Department of Clinical Sciences Lund, Division of Pediatrics, Lund University, Lund, Sweden.,Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Robin Kahn
- Department of Clinical Sciences Lund, Division of Pediatrics, Lund University, Lund, Sweden.,Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Fredrik Kahn
- Department of Clinical Sciences Lund, Division of Infection Medicine, Lund University, Lund, Sweden
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155
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Watkins RR, Bonomo RA, Rello J. Managing sepsis in the era of precision medicine: challenges and opportunities. Expert Rev Anti Infect Ther 2022; 20:871-880. [PMID: 35133228 DOI: 10.1080/14787210.2022.2040359] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Precision medicine is a medical model in which decisions, practices, interventions and therapies are tailored to the individual patient based on their predicted response or risk of disease. Sepsis is a life-threatening condition characterized by immune system dysregulation whose pathophysiology remains incompletely understood. There is much hope that precision medicine can lead to better outcomes in patients with sepsis. AREAS COVERED In this review from a comprehensive literature search in PubMed for English-language studies conducted in adults, we highlight recent advances in the diagnosis and treatment of sepsis of bacterial origin in adults using precision medicine approaches including rapid diagnostic tests, predictive biomarkers, genomic methods, rapid antimicrobial susceptibility testing, and monitoring cell mediated immunity. Challenges and directions for future research are also discussed. EXPERT OPINION Current diagnostic testing in sepsis relies primarily on conventional cultures (e.g. blood cultures), which are time-consuming and may delay critical therapeutic decisions. Nonculture-based techniques including nucleic acid amplification technologies (NAAT), other molecular methods (biomarkers), and genomic sequencing offer promise to overcome some of the inherent limitations seen with culture-based techniques.
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Affiliation(s)
- Richard R Watkins
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Robert A Bonomo
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Research Service, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, USA.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, OH, USA
| | - Jordi Rello
- Clinical Research in Pneumonia and Sepsis, Vall d'Hebron Institute of Research, Barcelona, Spain.,Clinical Research, Centre Hospitalier Universitaire Maribeau, Nimes, France
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156
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Kory P, Meduri GU, Iglesias J, Varon J, Cadegiani FA, Marik PE. "MATH+" Multi-Modal Hospital Treatment Protocol for COVID-19 Infection: Clinical and Scientific Rationale. J Clin Med Res 2022; 14:53-79. [PMID: 35317360 PMCID: PMC8912998 DOI: 10.14740/jocmr4658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
In December 2019, coronavirus disease 2019 (COVID-19), a severe respiratory illness caused by the new coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China. The greatest impact that COVID-19 had was on intensive care units (ICUs), given that approximately 20% of hospitalized cases developed acute respiratory failure (ARF) requiring ICU admission. Based on the assumption that COVID-19 represented a viral pneumonia and no anti-coronaviral therapy existed, nearly all national and international health care societies recommended "supportive care only" avoiding other therapies outside of randomized controlled trials, with a specific prohibition against the use of corticosteroids in treatment. However, early studies of COVID-19-associated ARF reported inexplicably high mortality rates, with frequent prolonged durations of mechanical ventilation (MV), even from centers expert in such supportive care strategies. These reports led the authors to form a clinical expert panel called the Front-Line COVID-19 Critical Care Alliance (www.flccc.net). The panel collaboratively reviewed the emerging clinical, radiographic, and pathological reports of COVID-19 while initiating multiple discussions among a wide clinical network of front-line clinical ICU experts from initial outbreak areas in China, Italy, and New York. Based on the shared early impressions of "what was working and what wasn't working", the increasing medical journal publications and the rapidly accumulating personal clinical experiences with COVID-19 patients, a treatment protocol was created for the hospitalized patients based on the core therapies of methylprednisolone, ascorbic acid, thiamine, heparin and non-antiviral co-interventions (MATH+). This manuscript reviews the scientific and clinical rationale behind MATH+ based on published in-vitro, pre-clinical, and clinical data in support of each medicine, with a special emphasis of studies supporting their use in the treatment of patients with viral syndromes and COVID-19 specifically.
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Affiliation(s)
- Pierre Kory
- Front Line Critical Care Consortium (FLCCC.org), Washington DC, USA
| | | | - Jose Iglesias
- Jersey Shore University Medical Center, Hackensack School of Medicine at Seton Hall, NJ, USA
| | - Joseph Varon
- University of Texas Health Science Center, Houston, TX, USA
| | | | - Paul E. Marik
- Front Line Critical Care Consortium (FLCCC.org), Washington DC, USA
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157
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Costa NA, Pereira AG, Sugizaki CSA, Vieira NM, Garcia LR, de Paiva SAR, Zornoff LAM, Azevedo PS, Polegato BF, Minicucci MF. Insights Into Thiamine Supplementation in Patients With Septic Shock. Front Med (Lausanne) 2022; 8:805199. [PMID: 35155482 PMCID: PMC8832096 DOI: 10.3389/fmed.2021.805199] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Septic shock is associated with unacceptably high mortality rates, mainly in developing countries. New adjunctive therapies have been explored to reduce global mortality related to sepsis. Considering that metabolic changes, mitochondrial dysfunction and increased oxidative stress are specific disorders within the path of septic shock, several micronutrients that could act in cellular homeostasis have been studied in recent decades. Thiamine, also known as vitamin B1, plays critical roles in several biological processes, including the metabolism of glucose, synthesis of nucleic acids and reduction of oxidative stress. Thiamine deficiency could affect up to 70% of critically ill patients, and thiamine supplementation appears to increase lactate clearance and decrease the vasopressor dose. However, there is no evident improvement in the survival of septic patients. Other micronutrients such as vitamin C and D, selenium and zinc have been tested in the same context but have not been shown to improve the outcomes of these patients. Some problems related to the neutrality of these clinical trials are the study design, doses, route, timing, length of intervention and the choice of endpoints. Recently, the concept that multi-micronutrient administration may be better than single-micronutrient administration has gained strength. In general, clinical trials consider the administration of a single micronutrient as a drug. However, the antioxidant defense is a complex system of endogenous agents in which micronutrients act as cofactors, and the physiological interactions between micronutrients are little discussed. In this context, the association of thiamine, vitamin C and corticoids was tested as an adjunctive therapy in septic shock resulting in a significant decrease in mortality. However, after these initial results, no other study conducted with this combination could reproduce those benefits. In addition, the use of low-dose corticosteroids is recommended in patients with septic shock who do not respond to vasopressors, which can affect the action of thiamine. Therefore, given the excellent safety profile, good biologic rationale and promising clinical studies, this review aims to discuss the mechanisms behind and the evidence for single or combined thiamine supplementation improving the prognosis of patients with septic shock.
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Affiliation(s)
- Nara Aline Costa
- Faculty of Nutrition, Universidade Federal de Goiás (UFG), Goiânia, Brazil
| | - Amanda Gomes Pereira
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | | | - Nayane Maria Vieira
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Leonardo Rufino Garcia
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | | | | | - Paula Schmidt Azevedo
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Bertha Furlan Polegato
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Marcos Ferreira Minicucci
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
- *Correspondence: Marcos Ferreira Minicucci
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158
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Rosengrave P, Spencer E, Williman J, Mehrtens J, Morgan S, Doyle T, Van Der Heyden K, Morris A, Shaw G, Carr AC. Intravenous vitamin C administration to patients with septic shock: a pilot randomised controlled trial. Crit Care 2022; 26:26. [PMID: 35073968 PMCID: PMC8786621 DOI: 10.1186/s13054-022-03900-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/16/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Intravenous vitamin C administration in septic shock may have a sparing effect on vasopressor requirements, and vitamin C's enzyme cofactor functions provide a mechanistic rationale. Our study aimed to determine the effect of intravenous vitamin C administration on vasopressor requirements and other outcomes in patients with septic shock. METHODS This was a double-blind, randomised placebo-controlled trial in 40 patients with septic shock who were randomised (1:1) to receive intravenous vitamin C (at a dose of 25 mg/kg of body weight every 6 h) or placebo (intravenous 5% dextrose) for up to 96 h, or until death or discharge. The primary outcome was intravenous vasopressor requirements (dose and duration), and secondary outcomes included Sequential Organ Failure Assessment (SOFA) scores, intensive care unit (ICU) and hospital length of stay, and mortality. In addition, blood samples were collected to determine vitamin C kinetics and inflammatory marker concentrations. RESULTS Median plasma vitamin C concentrations were deficient at baseline (9.2 [4.4, 12] µmol/L) and increased to 408 (227, 560) µmol/L following 72 h of intervention. The mean duration of intravenous vasopressor infusion in the vitamin C group was 48 (95% CI 35-62) hours and in the placebo group was 54 (95% CI 41-62) hours (p = 0.52). The dose of vasopressor delivered over time was comparable between the two groups, as were SOFA scores (p > 0.05). The median ICU length of stay in the intervention group was 3.8 (2.2, 9.8) days versus 7.1 (3.1, 20) days in the placebo group (p = 0.12). The median hospital length of stay for the vitamin C group was 18 (11, 35) days versus 22 (10, 52) days for the placebo group (p = 0.65). Mortality was comparable between the two groups (p > 0.05). Of the inflammatory markers, neutrophil counts were elevated in the vitamin C group relative to placebo by 72 h (p = 0.01). C-reactive protein and myeloperoxidase concentrations were elevated at baseline, however, the two groups were comparable over time (p > 0.05). CONCLUSIONS Our pilot study indicated that intravenous vitamin C did not provide significant decreases in the mean dose or duration of vasopressor infusion. Further research that takes into account the potential impact of intervention timing, dose and duration, and location of trial, may provide more definitive evidence. TRIAL REGISTRATION ACTRN12617001184369 (11/8/2017).
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Affiliation(s)
- Patrice Rosengrave
- Department of Pathology and Biomedical Science, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand
- Centre for Postgraduate Nursing Studies, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand
| | - Emma Spencer
- Department of Pathology and Biomedical Science, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand
| | - Jonathan Williman
- Department of Population Health, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand
| | - Jan Mehrtens
- Department of Intensive Care Medicine, Christchurch Hospital, Private Bag 4710, Christchurch, 8140, New Zealand
| | - Stacey Morgan
- Department of Intensive Care Medicine, Christchurch Hospital, Private Bag 4710, Christchurch, 8140, New Zealand
| | - Tara Doyle
- Department of Intensive Care Medicine, Christchurch Hospital, Private Bag 4710, Christchurch, 8140, New Zealand
| | - Kymbalee Van Der Heyden
- Department of Intensive Care Medicine, Christchurch Hospital, Private Bag 4710, Christchurch, 8140, New Zealand
| | - Anna Morris
- Department of Intensive Care Medicine, Christchurch Hospital, Private Bag 4710, Christchurch, 8140, New Zealand
| | - Geoff Shaw
- Department of Intensive Care Medicine, Christchurch Hospital, Private Bag 4710, Christchurch, 8140, New Zealand
| | - Anitra C Carr
- Department of Pathology and Biomedical Science, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand.
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159
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Lazzaro A, De Girolamo G, Filippi V, Innocenti GP, Santinelli L, Ceccarelli G, Trecarichi EM, Torti C, Mastroianni CM, d’Ettorre G, Russo A. The Interplay between Host Defense, Infection, and Clinical Status in Septic Patients: A Narrative Review. Int J Mol Sci 2022; 23:ijms23020803. [PMID: 35054993 PMCID: PMC8776148 DOI: 10.3390/ijms23020803] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/09/2022] [Indexed: 01/08/2023] Open
Abstract
Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. Despite significant morbidity and mortality throughout the world, its pathogenesis and mechanisms are not clearly understood. In this narrative review, we aimed to summarize the recent developments in our understanding of the hallmarks of sepsis pathogenesis (immune and adaptive immune response, the complement system, the endothelial disfunction, and autophagy) and highlight novel laboratory diagnostic approaches. Clinical management is also discussed with pivotal consideration for antimicrobic therapy management in particular settings, such as intensive care unit, altered renal function, obesity, and burn patients.
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Affiliation(s)
- Alessandro Lazzaro
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00161 Rome, Italy; (A.L.); (G.D.G.); (V.F.); (G.P.I.); (L.S.); (G.C.); (C.M.M.); (G.d.)
| | - Gabriella De Girolamo
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00161 Rome, Italy; (A.L.); (G.D.G.); (V.F.); (G.P.I.); (L.S.); (G.C.); (C.M.M.); (G.d.)
| | - Valeria Filippi
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00161 Rome, Italy; (A.L.); (G.D.G.); (V.F.); (G.P.I.); (L.S.); (G.C.); (C.M.M.); (G.d.)
| | - Giuseppe Pietro Innocenti
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00161 Rome, Italy; (A.L.); (G.D.G.); (V.F.); (G.P.I.); (L.S.); (G.C.); (C.M.M.); (G.d.)
| | - Letizia Santinelli
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00161 Rome, Italy; (A.L.); (G.D.G.); (V.F.); (G.P.I.); (L.S.); (G.C.); (C.M.M.); (G.d.)
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00161 Rome, Italy; (A.L.); (G.D.G.); (V.F.); (G.P.I.); (L.S.); (G.C.); (C.M.M.); (G.d.)
| | - Enrico Maria Trecarichi
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy; (E.M.T.); (C.T.)
| | - Carlo Torti
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy; (E.M.T.); (C.T.)
| | - Claudio Maria Mastroianni
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00161 Rome, Italy; (A.L.); (G.D.G.); (V.F.); (G.P.I.); (L.S.); (G.C.); (C.M.M.); (G.d.)
| | - Gabriella d’Ettorre
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00161 Rome, Italy; (A.L.); (G.D.G.); (V.F.); (G.P.I.); (L.S.); (G.C.); (C.M.M.); (G.d.)
| | - Alessandro Russo
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy; (E.M.T.); (C.T.)
- Correspondence:
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Zhou X, Liao Y. Gut-Lung Crosstalk in Sepsis-Induced Acute Lung Injury. Front Microbiol 2022; 12:779620. [PMID: 35003009 PMCID: PMC8733643 DOI: 10.3389/fmicb.2021.779620] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/06/2021] [Indexed: 12/16/2022] Open
Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are common acute and severe cases of the respiratory system with complicated pathogenesis and high mortality. Sepsis is the leading indirect cause of ALI/ARDS in the intensive care unit (ICU). The pathogenesis of septic ALI/ARDS is complex and multifactorial. In the development of sepsis, the disruption of the intestinal barrier function, the alteration of gut microbiota, and the translocation of the intestinal microbiome can lead to systemic and local inflammatory responses, which further alter the immune homeostasis in the systemic environment. Disruption of homeostasis may promote and propagate septic ALI/ARDS. In turn, when ALI occurs, elevated levels of inflammatory cytokines and the shift of the lung microbiome may lead to the dysregulation of the intestinal microbiome and the disruption of the intestinal mucosal barrier. Thus, the interaction between the lung and the gut can initiate and potentiate sepsis-induced ALI/ARDS. The gut–lung crosstalk may be a promising potential target for intervention. This article reviews the underlying mechanism of gut-lung crosstalk in septic ALI/ARDS.
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Affiliation(s)
- Xin Zhou
- Department of ICU/Emergency, Wuhan University, Wuhan Third Hospital, Wuhan, China
| | - Youxia Liao
- Department of ICU/Emergency, Wuhan University, Wuhan Third Hospital, Wuhan, China
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Ruiz-Rodriguez JC, Plata-Menchaca EP, Chiscano-Camón L, Ruiz-Sanmartin A, Pérez-Carrasco M, Palmada C, Ribas V, Martínez-Gallo M, Hernández-González M, Gonzalez-Lopez JJ, Larrosa N, Ferrer R. Precision medicine in sepsis and septic shock: From omics to clinical tools. World J Crit Care Med 2022; 11:1-21. [PMID: 35433311 PMCID: PMC8788206 DOI: 10.5492/wjccm.v11.i1.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/23/2021] [Accepted: 12/22/2021] [Indexed: 02/06/2023] Open
Abstract
Sepsis is a heterogeneous disease with variable clinical course and several clinical phenotypes. As it is associated with an increased risk of death, patients with this condition are candidates for receipt of a very well-structured and protocolized treatment. All patients should receive the fundamental pillars of sepsis management, which are infection control, initial resuscitation, and multiorgan support. However, specific subgroups of patients may benefit from a personalized approach with interventions targeted towards specific pathophysiological mechanisms. Herein, we will review the framework for identifying subpopulations of patients with sepsis, septic shock, and multiorgan dysfunction who may benefit from specific therapies. Some of these approaches are still in the early stages of research, while others are already in routine use in clinical practice, but together will help in the effective generation and safe implementation of precision medicine in sepsis.
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Affiliation(s)
- Juan Carlos Ruiz-Rodriguez
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Erika P Plata-Menchaca
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Department of Intensive Care, Hospital Clínic de Barcelona, Barcelona 08036, Spain
| | - Luis Chiscano-Camón
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Adolfo Ruiz-Sanmartin
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Marcos Pérez-Carrasco
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
| | - Clara Palmada
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
| | - Vicent Ribas
- Data Analytics in Medicine, Digital Health Unit, Eurecat, Centre Tecnològic de Catalunya, Barcelona 08005, Spain
| | - Mónica Martínez-Gallo
- Immunology Division, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Diagnostic Immunology Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Manuel Hernández-González
- Immunology Division, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Diagnostic Immunology Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Juan J Gonzalez-Lopez
- Department of Clinical Microbiology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Department of Microbiology and Genetics, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Nieves Larrosa
- Department of Clinical Microbiology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Department of Microbiology and Genetics, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Ricard Ferrer
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
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Jung SY, Lee MT, Baek MS, Kim WY. Vitamin C for ≥ 5 days is associated with decreased hospital mortality in sepsis subgroups: a nationwide cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2022; 26:3. [PMID: 34983595 PMCID: PMC8728994 DOI: 10.1186/s13054-021-03872-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/11/2021] [Indexed: 12/29/2022]
Abstract
Background Previous randomized trials of vitamin C, hydrocortisone, and thiamine on sepsis were limited by short-term vitamin C administration, heterogeneous populations, and the failure to evaluate each component’s effect. The purpose of this study was to determine whether vitamin C alone for ≥ 5 days or in combination with corticosteroids and/or thiamine was associated with decreased mortality across the sepsis population and subpopulation.
Methods Nationwide population-based study conducted using the Korean National Health Insurance Service database. A total of 384,282 adult patients with sepsis who were admitted to the intensive care unit were enrolled from January 2017 to December 2019. The primary outcome was hospital mortality, while the key secondary outcome was 90-day mortality. Results The mean [standard deviation] age was 69.0 [15.4] years; 57% were male; and 36,327 (9%) and 347,955 did and did not receive vitamin C, respectively. After propensity score matching, each group involved 36,327 patients. The hospital mortality was lower by − 0.9% in the treatment group (17.1% vs 18.0%; 95% confidence interval, − 1.3 to − 0.5%; p < 0.001), a significant but extremely small difference. However, mortality decreased greater in patients who received vitamin C for ≥ 5 days (vs 1–2 or 3–4 days) (15.8% vs 18.8% vs 18.3%; p < 0.001). Further, vitamin C was associated with a lower hospital mortality in patients with older age, multiple comorbidities, pneumonia, genitourinary infection, septic shock, and mechanical ventilation. Consistent findings were found for 90-day mortality. Moreover, vitamin C alone or in combination with thiamine was significantly associated with decreased hospital mortality. Conclusions Intravenous vitamin C of ≥ 5 days was significantly associated with decreased hospital and 90-day mortality in sepsis patients. Vitamin C combined with corticosteroids and/or thiamine in specific sepsis subgroups warrants further study. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03872-3.
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Affiliation(s)
- Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea.,Department of Global Innovative Drugs, The Graduate School of Chung-Ang University, Chung-Ang University, Seoul, Republic of Korea
| | - Min-Taek Lee
- Department of Global Innovative Drugs, The Graduate School of Chung-Ang University, Chung-Ang University, Seoul, Republic of Korea
| | - Moon Seong Baek
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Won-Young Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea.
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Abstract
Vitamins are essential micronutrients with key roles in many biological pathways relevant to sepsis. Some of these relevant biological mechanisms include antioxidant and anti-inflammatory effects, protein and hormone synthesis, energy generation, and regulation of gene transcription. Moreover, relative vitamin deficiencies in plasma are common during sepsis and vitamin therapy has been associated with improved outcomes in some adult and pediatric studies. High-dose intravenous vitamin C has been the vitamin therapy most extensively studied in adult patients with sepsis and septic shock. This includes three randomized control trials (RCTs) as monotherapy with a total of 219 patients showing significant reduction in organ dysfunction and lower mortality when compared to placebo, and five RCTs as a combination therapy with thiamine and hydrocortisone with a total of 1134 patients showing no difference in clinical outcomes. Likewise, the evidence for the role of other vitamins in sepsis remains mixed. In this narrative review, we present the preclinical, clinical, and safety evidence of the most studied vitamins in sepsis, including vitamin C, thiamine (i.e., vitamin B1), and vitamin D. We also present the relevant evidence of the other vitamins that have been studied in sepsis and critical illness in both children and adults, including vitamins A, B2, B6, B12, and E. IMPACT: Vitamins are key effectors in many biological processes relevant to sepsis. We present the preclinical, clinical, and safety evidence of the most studied vitamins in pediatric sepsis. Designing response-adaptive platform trials may help fill in knowledge gaps regarding vitamin use for critical illness and association with clinical outcomes.
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Nandhini N, Malviya D, Parashar S, Pandey C, Nath SS, Tripathi M. Comparison of the effects of vitamin C and thiamine on refractory hypotension in patients with sepsis: A randomized controlled trial. Int J Crit Illn Inj Sci 2022; 12:138-145. [PMID: 36506923 PMCID: PMC9728072 DOI: 10.4103/ijciis.ijciis_107_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 12/15/2022] Open
Abstract
Background The study aimed to compare the effect of thiamine and ascorbic acid (AA) on mortality, sequential organ failure assessment (SOFA) score, duration and dose of vasopressor support, and need for renal replacement therapy (RRT) in patients with septic shock with refractory hypotension. Methods Consenting adult patients with septic shock and refractory hypotension were included in this study. Patients were divided into three groups: Group A received 100 ml of balanced salt solution 8 hourly, Group B received 2 mg/kg of thiamine 8 hourly, Group C received 25 mg/kg of AA 8 hourly intravenous (IV) for 72 h. All patients received IV infusion of hydrocortisone 200 mg/day for 72 h. Serum lactate, dose and duration of vasopressor support, SOFA score, need for RRT and hospital mortality were analyzed. Results The SOFA Score was significantly lower in Group B than in Group A and C at 24, 48, and 72 h. Dosage of norepinephrine was lower in Group B at 66 h and after that, whereas in Groups A and C, it was comparable at all time points. Mortality in Group B was significantly lower but comparable in Groups A and C. The need for RRT was significantly lower in Group B (44%) compared to the control group (88%) but comparable in Group C (76%). Conclusion In patients with septic shock treated with hydrocortisone, co-treatment with thiamine led to earlier correction of organ dysfunction, reduced need for RRT, and improved mortality compared to patients treated with AA or balanced salt solution. The addition of AA did not yield measurable benefits beyond hydrocortisone alone.
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Affiliation(s)
- N Nandhini
- Department of Anesthesiology and Critical Care Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Deepak Malviya
- Department of Anesthesiology and Critical Care Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Samiksha Parashar
- Department of Anesthesiology and Critical Care Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Chandrakant Pandey
- Department of Anesthesiology, Medanta Hospital, Lucknow, Uttar Pradesh, India
| | - Soumya Sankar Nath
- Department of Anesthesiology and Critical Care Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India,Address for correspondence: Dr. Soumya Sankar Nath, Department of Anaesthesiology and Critical Care Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Lucknow - 226 010, Uttar Pradesh, India. E-mail:
| | - Manoj Tripathi
- Department of Anesthesiology and Critical Care Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Park JE, Jo YH, Hwang SY, Kim WY, Ryoo SM, Jang DH, Kim T, Kim YJ, Kim S, Cho H, Lee GT, Chung SP, Choi SH, Shin TG, Suh GJ. Biomarker Analysis for Combination Therapy of Vitamin C and Thiamine in Septic Shock: A Post-Hoc Study of the ATESS Trial. Shock 2022; 57:81-87. [PMID: 34482319 DOI: 10.1097/shk.0000000000001850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION We evaluated the effects of vitamin C and thiamine administration on biomarkers in patients with septic shock. METHODS This was a post-hoc analysis of the Ascorbic Acid and Thiamine Effect in Septic Shock (ATESS) trial, a multicenter, double-blind, randomized controlled trial. Patients were randomized to either a treatment group (intravenous vitamin C and thiamine for 48 h) or a control group. Interleukin (IL)-6, IL-10, angiopoietin-II (AP2), and S100β were assessed at baseline and at 72 h. The primary outcomes were the biomarker levels at 72 h, and the secondary outcome was reduction rate. RESULTS Forty-five patients were assigned to the treatment group and 52 were assigned to the control group. Baseline biomarker levels and at 72 h were not significantly different between the treatment and the placebo groups. The reduction rates were not significantly different between the two groups. These outcome variables showed fair diagnostic accuracy for predicting 28-day mortality according to the area under the receiver operating characteristic curve. CONCLUSION Vitamin C and thiamine administration during the early phase of septic shock did not significantly change prognostic biomarker levels of IL-6, IL-10, AP2, and S100β. TRIAL REGISTRATION NCT, ClinicalTrials.gov NCT03756220, ATESS. Registered 28 November 2018, https://clinicaltrials.gov/ct2/show/NCT03756220.
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Affiliation(s)
- Jong Eun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hyun Jang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Taegyun Kim
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seonwoo Kim
- Statistics and Data Center, Samsung Medical Center, Seoul, Korea
| | - Hyun Cho
- Statistics and Data Center, Samsung Medical Center, Seoul, Korea
| | - Gun Tak Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Guro Hospital, Korea University Medical Center, Seoul, Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
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Medeiros PMC, Schjalm C, Christiansen D, Sokolova M, Pischke SE, Würzner R, Mollnes TE, Barratt-Due A. Vitamin C, Hydrocortisone, and the Combination Thereof Significantly Inhibited Two of Nine Inflammatory Markers Induced by Escherichia Coli But Not by Staphylococcus Aureus - When Incubated in Human Whole Blood. Shock 2022; 57:72-80. [PMID: 34265830 PMCID: PMC8663529 DOI: 10.1097/shk.0000000000001834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/29/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT Vitamin C combined with hydrocortisone is increasingly being used to treat septic patients, even though this treatment regimen is based on questionable evidence. When used, a marked effect on key players of innate immunity would be expected, as sepsis is featured by a dysregulated immune response.Here, we explored the effect of vitamin C and hydrocortisone alone and combined, in an ex vivo human whole-blood model of Escherichia coli- or Staphylococcus aureus-induced inflammation. Inflammatory markers for activation of complement (terminal C5b-9 complement complex [TCC]), granulocytes (myeloperoxidase), platelets (β-thromboglobulin), cytokines (tumor necrosis factor [TNF], IL-1β, IL6, and IL-8), and leukocytes (CD11b and oxidative burst) were quantified, by enzyme-linked immunosorbent assay, multiplex technology, and flow cytometry.In E. coli- and S. aureus-stimulated whole blood, a broad dose-titration of vitamin C and hydrocortisone alone did not lead to dose-response effects for the central innate immune mediators TCC and IL-6. Hence, the clinically relevant doses were used further. Compared to the untreated control sample, two of the nine biomarkers induced by E. coli were reduced by hydrocortisone and/or vitamin C. TNF was reduced by hydrocortisone alone (19%, P = 0.01) and by the combination (31%, P = 0.01). The oxidative burst of monocytes and granulocytes was reduced for both drugs alone and their combination, (ranging 8-19%, P < 0.05). Using S. aureus, neither of the drugs, alone nor in combination, had any effects on the nine biomarkers.In conclusion, despite the limitation of the ex vivo model, the effect of vitamin C and hydrocortisone on bacteria-induced inflammatory response in human whole blood is limited and following the clinical data.
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Affiliation(s)
| | - Camilla Schjalm
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Dorte Christiansen
- Research Laboratory, Nordland Hospital, Bodø and Faculty of Health Sciences, K. G. Jebsen Center, University of Tromsø, Norway
| | - Marina Sokolova
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Soeren Erik Pischke
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Reinhard Würzner
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tom Eirik Mollnes
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Research Laboratory, Nordland Hospital, Bodø and Faculty of Health Sciences, K. G. Jebsen Center, University of Tromsø, Norway
- Center of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Andreas Barratt-Due
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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Oxidation and “Unconventional” Approaches to Infection. ENCYCLOPEDIA OF INFECTION AND IMMUNITY 2022. [PMCID: PMC8575407 DOI: 10.1016/b978-0-12-818731-9.00182-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Nonpharmacological approaches can be useful to control infectious diseases. Historically infection has been successfully managed with oxidation therapy methods that support the body's own innate defenses. Several modalities include ozone and hyperbaric oxygen therapy, ultraviolet blood irradiation (UBI), intravenous hydrogen peroxide, and ascorbate therapies. Oxidation therapies are virtually 100% safe, and repeatedly reported as highly and quickly effective in quelling infection (bacterial and viral) either as stand-alone therapies or adjunctive with drugs. They are directly and indirectly germicidal, and modulate the immune system via pro-oxidant signaling molecules. Oxidation therapies especially enhance oxygen delivery and metabolism, critical for all infection defenses. Ozone has remitted Ebola, COVID-19, and bacterial infections. UBI defeated most preantibiotic era infections in hospitals. Not being drug therapy, the effects of oxidation defenses, used by planetary animal life for millions of years, are not diminished by antibiotic-resistant organisms. Oxidation, depending on delivery method, can be very inexpensive and third world adaptable. This chapter summarizes the use of these key modalities, by exploring known published literature.
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Rabby MII, Hossain F, Islam MA, Islam AS, Akhi IJ, Akter F. Impact of supplemental vitamins and natural honey for treatment of COVID-19: A review. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902022e20607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Toledano JM, Moreno-Fernandez J, Puche-Juarez M, Ochoa JJ, Diaz-Castro J. Implications of Vitamins in COVID-19 Prevention and Treatment through Immunomodulatory and Anti-Oxidative Mechanisms. Antioxidants (Basel) 2021; 11:antiox11010005. [PMID: 35052509 PMCID: PMC8773198 DOI: 10.3390/antiox11010005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022] Open
Abstract
Since the appearance of the coronavirus disease 2019 (COVID-19) and its announcement as a global pandemic, the search for prophylactic and therapeutic options have become a priority for governments and the scientific community. The approval of several vaccines against SARS-CoV-2 is being crucial to overcome this situation, although the victory will not be achieved while the whole population worldwide is not protected against the virus. This is why alternatives should be studied in order to successfully support the immune system before and during a possible infection. An optimal inflammatory and oxidative stress status depends on an adequate diet. Poor levels of several nutrients could be related to an impaired immune response and, therefore, an increased susceptibility to infection and serious outcomes. Vitamins exert a number of anti-microbial, immunomodulatory, anti-inflammatory, and antioxidant activities, which can be of use to fight against this and several other diseases (especially vitamin D and C). Even though they cannot be considered as a definitive therapeutic option, in part owing to the lack of solid conclusions from well-designed clinical trials, currently available evidence from similar respiratory diseases may indicate that it would be rational to deeply explore the use of vitamins during this global pandemic.
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Affiliation(s)
- Juan M. Toledano
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, University of Granada, 18071 Granada, Spain; (J.M.T.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, 18071 Granada, Spain
- Nutrition and Food Sciences Ph.D. Program, University of Granada, 18071 Granada, Spain
| | - Jorge Moreno-Fernandez
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, University of Granada, 18071 Granada, Spain; (J.M.T.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, 18071 Granada, Spain
- Correspondence: (J.M.-F.); (M.P.-J.); (J.J.O.)
| | - María Puche-Juarez
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, University of Granada, 18071 Granada, Spain; (J.M.T.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, 18071 Granada, Spain
- Nutrition and Food Sciences Ph.D. Program, University of Granada, 18071 Granada, Spain
- Correspondence: (J.M.-F.); (M.P.-J.); (J.J.O.)
| | - Julio J. Ochoa
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, University of Granada, 18071 Granada, Spain; (J.M.T.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, 18071 Granada, Spain
- Correspondence: (J.M.-F.); (M.P.-J.); (J.J.O.)
| | - Javier Diaz-Castro
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, University of Granada, 18071 Granada, Spain; (J.M.T.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, 18071 Granada, Spain
- Instituto de Investigación Biosanitaria (IBS), 18016 Granada, Spain
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Na W, Shen H, Li Y, Qu D. Hydrocortisone, ascorbic acid, and thiamine (HAT) for sepsis and septic shock: a meta-analysis with sequential trial analysis. J Intensive Care 2021; 9:75. [PMID: 34922637 PMCID: PMC8684090 DOI: 10.1186/s40560-021-00589-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/01/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Sepsis is a primary global health threat and costs a lot, requiring effective and affordable treatments. We performed this meta-analysis to explore the treatment of hydrocortisone, ascorbic acid, and thiamine (HAT) in sepsis and septic shock. METHODS We searched Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to August 14, 2021. We included randomized controlled trials (RCTs) that evaluated the HAT treatments in sepsis and septic shock. The primary outcome was the change in SOFA score over the 72 h. The second outcomes were the hospital, and 28-/30-day mortality, the duration of vasopressors, PCT clearance, hospital length of stay (LOS), and ICU LOS. We performed a subgroup analysis and a trial sequential analysis (TSA). The Der Simonian-Laird random-effects models were used to report the pooled risk ratios (RR) or mean difference (MD) with confidence intervals (CI). RESULTS Nine RCTs, enrolling 1427 patients of sepsis and septic shock treated with HAT (717) or only standard care (710), were included. There was a significant difference between the two groups in the change in SOFA score over the first 72 h (MD 0.65, 95% CI 0.30 to 1.00), the duration of vasopressors (MD - 18.16, 95% CI - 25.65 to - 10.68) and the PCT clearance (MD 14.54, 95% CI 0.64 to 28.43). In addition, there was no significant difference in the hospital mortality (RR 1.07, 95% CI 0.85 to 1.34), the 28-/30-day mortality (RR 0.96, 95% CI 0.80 to 1.15), the hospital LOS (MD 0.78, 95% CI - 0.30 to 1.86), and ICU LOS (MD 0.12, 95% CI - 0.53 to 0.78). CONCLUSIONS The HAT combination improves the SOFA score in the first 72 h and reduces the duration of vasopressors in patients with sepsis. Given the minor mean difference of the change in SOFA score, the mortality benefit has not been observed. TRIAL REGISTRATION PROSPERO, CRD42020203166.
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Affiliation(s)
- Weilan Na
- Department of Critical Medicine, Children's Hospital Affiliated to the Capital Institute of Pediatrics, NO.2 Ya Bao Road, Chaoyang District, Beijing, 100020, China
| | - Huili Shen
- Pediatric Intensive Care Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 100020, China
| | - Yichu Li
- Department of Critical Medicine, Children's Hospital Affiliated to the Capital Institute of Pediatrics, NO.2 Ya Bao Road, Chaoyang District, Beijing, 100020, China
| | - Dong Qu
- Department of Critical Medicine, Children's Hospital Affiliated to the Capital Institute of Pediatrics, NO.2 Ya Bao Road, Chaoyang District, Beijing, 100020, China.
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171
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Kamel NA, Soliman MM, Abo-Zeid MA, Shaaban MI. Effect of Anti-Inflammatory and Antimicrobial Cosupplementations on Sepsis Prevention in Critically Ill Trauma Patients at High Risk for Sepsis. Front Pharmacol 2021; 12:792741. [PMID: 34912231 PMCID: PMC8666620 DOI: 10.3389/fphar.2021.792741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/01/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Sepsis development in patients with trauma is associated with bad prognosis. This study investigated the effect of immunomodulatory interventions in major trauma patients at high risk for sepsis. Methods: In a randomized, double-blinded, controlled design, severe trauma patients were stratified by leukocyte anti-sedimentation rate (LAR) test into high risk (HR) and low risk (LR) for sepsis. The HR patients were randomly allocated into intravenous vitamin C plus vitamin B1 (HR-CB), intramuscular vitamin D plus oral Lactobacillus probiotics (HR-DP), or control (HR-C) groups. The clinical trial was registered at clinicaltrials.gov (https://clinicaltrials.gov/show/NCT04216459). Outcomes: The primary outcome was Acute Physiologic Assessment and Chronic Health Evaluation score II (APACHE II) score. Secondary outcomes included sepsis incidence, changes in Sequential Organ Failure Assessment (SOFA) score, and serum monocyte chemoattractant protein-1 (MCP-1) on day 6 from baseline, 28-day mortality, intensive care unit (ICU), and hospital discharge. Results: The HR-DP, HR-CB, and LR groups showed a significantly lower incidence of sepsis development (20%, 20%, and 16%, respectively, versus 60% in the HR-C group, p-value = 0.004). The three groups also showed a significant improvement in APACHE II and SOFA scores. Besides, MCP-1 levels were significantly decreased in HR-DP and HR-CB groups compared to the HR-C group (p-value ≤ 0.05). Significantly decreased mortality (10% and 16% versus 60% in the HR-C group) and increased ICU discharge (95% and 84% versus 45% in the HR-C group) were observed in HR-CB and LR groups (p-value = 0.001). Conclusion: Both combinations of interventions improved APACHE II scores and reduced sepsis incidence in trauma patients. The LAR combined with injury severity score were good sepsis predictors.
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Affiliation(s)
- Noha A Kamel
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
| | - Moetaza M Soliman
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
| | - Maha A Abo-Zeid
- Department of Anesthesia, Surgical Intensive Care Unit and Pain Management, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mona I Shaaban
- Department of Microbiology and Immunology, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
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Yao R, Zhu Y, Yu Y, Li Z, Wang L, Zheng L, Li J, Huang H, Wu G, Zhu F, Xia Z, Ren C, Yao Y. Combination therapy of thiamine, vitamin C and hydrocortisone in treating patients with sepsis and septic shock: a meta-analysis and trial sequential analysis. BURNS & TRAUMA 2021; 9:tkab040. [PMID: 34901285 PMCID: PMC8660008 DOI: 10.1093/burnst/tkab040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/12/2021] [Indexed: 12/29/2022]
Abstract
Background The objective of this study was to evaluate the clinical efficacy of thiamine and vitamin C with or without hydrocortisone coadministration on the treatment of sepsis and septic shock. Methods MEDLINE, EMBASE and CENTRAL databases were searched for randomized controlled trials (RCTs) that made a comparative study between the combination therapy of vitamin C and thiamine with or without hydrocortisone and the administration of placebo in patients with sepsis or septic shock. Two reviewers independently performed study selection, data extraction and quality assessment. Both short-term mortality and change in the sequential organ failure assessment (SOFA) score from baseline (delta SOFA) were set as the primary outcomes. Secondary endpoints included intensive care unit (ICU) mortality, new onset of acute kidney injury, total adverse events, ICU and hospital length of stay, duration of vasopressor usage and ventilator-free days. Meanwhile, trial sequential analysis was conducted for primary outcomes. Results Eight RCTs with 1428 patients were included in the current study. The results showed no significant reduction of short-term mortality in sepsis and septic shock patients who received combination therapy of vitamin C and thiamine with or without hydrocortisone compared to those with placebo {risk ratio (RR), 1.02 [95% confidence interval (CI), 0.87 to 1.20], p = 0.81, I2 = 0%; risk difference (RD), 0 [95% CI, −0.04 to 0.05]}. Nevertheless, the combination therapy was associated with significant reduction in SOFA score [mean difference (MD), −0.63, (95% CI, −0.96 to −0.29, p < 0.001, I2 = 0%] and vasopressors duration (MD, −22.11 [95% CI, −30.46 to −13.77], p < 0.001, I2 = 6%). Additionally, there were no statistical differences in the pooled estimate for other outcomes. Conclusions In the current meta-analysis, the combination therapy of vitamin C and thiamine, with or without hydrocortisone had no impact on short-term mortality when compared with placebo, but was associated with significant reduction in SOFA score among patients with sepsis and septic shock.
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Affiliation(s)
- Renqi Yao
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
| | - Yibing Zhu
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yue Yu
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Zhixuan Li
- International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Institute, Second Military Medical University, Shanghai 200082, China
| | - Lixue Wang
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
| | - Liyu Zheng
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
| | - Jingyan Li
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
| | - Huibin Huang
- Department of Critical Care Medicine, Beijing Tsinghua Chang Gung Hospital, Beijing 102218, China
| | - Guosheng Wu
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, Shanghai 200433, China
| | - Feng Zhu
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Zhaofan Xia
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, Shanghai 200433, China
| | - Chao Ren
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
| | - Yongming Yao
- Translational Medicine Research Center, Fourth Medical Center and Medical Innovation Research Division of the Chinese PLA General Hospital, Beijing 100048, China
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Uddin MS, Millat MS, Baral PK, Ferdous M, Uddin MG, Sarwar MS, Islam MS. The protective role of vitamin C in the management of COVID-19: A Review. JOURNAL OF THE EGYPTIAN PUBLIC HEALTH ASSOCIATION 2021; 96:33. [PMID: 34894332 PMCID: PMC8665316 DOI: 10.1186/s42506-021-00095-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/13/2021] [Indexed: 12/22/2022]
Abstract
Background The outbreak of coronavirus infectious disease-2019 (COVID-19) is globally deemed a significant threat to human life. Researchers are searching for prevention strategies, mitigation interventions, and potential therapeutics that may reduce the infection’s severity. One such means that is highly being talked in online and in social media is vitamin C. Main text Vitamin C is a robust antioxidant that boosts the immune system of the human body. It helps in normal neutrophil function, scavenging of oxidative species, regeneration of vitamin E, modulation of signaling pathways, activation of pro-inflammatory transcription factors, activation of the signaling cascade, regulation of inflammatory mediators, and phagocytosis and increases neutrophil motility to the site of infection. All of these immunological functions are required for the prevention of COVID-19 infection. Conclusion Considering the role of vitamin C, it would be imperative to administrate vitamin C for the management of severe COVID-19. However, there is no specific clinical data available to confirm the use of vitamin C in the current pandemic.
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Affiliation(s)
- Mohammad Sarowar Uddin
- Department of Pharmacy, Noakhali Science & Technology University, Noakhali, 3814, Bangladesh.
| | - Md Shalahuddin Millat
- Department of Pharmacy, Noakhali Science & Technology University, Noakhali, 3814, Bangladesh
| | - Prodip Kumar Baral
- Department of Pharmacy, Noakhali Science & Technology University, Noakhali, 3814, Bangladesh
| | - Mahmuda Ferdous
- Department of Pharmacy, Noakhali Science & Technology University, Noakhali, 3814, Bangladesh
| | - Md Giash Uddin
- Department of Pharmacy, University of Chittagong, Chittagong, 4331, Bangladesh
| | - Md Shahid Sarwar
- Department of Pharmacy, Noakhali Science & Technology University, Noakhali, 3814, Bangladesh
| | - Mohammad Safiqul Islam
- Department of Pharmacy, Noakhali Science & Technology University, Noakhali, 3814, Bangladesh
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174
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Winters ME, Hu K, Martinez JP, Mallemat H, Brady WJ. The critical care literature 2020. Am J Emerg Med 2021; 50:683-692. [PMID: 34879487 PMCID: PMC8485063 DOI: 10.1016/j.ajem.2021.09.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
Given the dramatic increase in critically ill patients who present to the emergency department for care, along with the persistence of boarding of critically ill patients, it is imperative for the emergency physician to be knowledgeable about recent developments in resuscitation and critical care medicine. This review summarizes important articles published in 2020 that pertain to the resuscitation and care of select critically ill patients. These articles have been selected based on the authors annual review of key critical care, emergency medicine and medicine journals and their opinion of the importance of study findings as it pertains to the care of critically ill ED patients. Several key findings from the studies discussed in this paper include the administration of dexamethasone to patients with COVID-19 infection who require mechanical ventilation or supplemental oxygen, the use of lower levels of positive end-expiratory pressure for patients without acute respiratory distress syndrome, and early initiation of extracorporeal membrane oxygenation for out-of-hospital cardiac arrest patients with refractory ventricular fibrillation if resources are available. Furthermore, the emergency physician should not administer tranexamic acid to patients with acute gastrointestinal bleeding or administer the combination of vitamin C, thiamine, and hydrocortisone for patients with septic shock. Finally, the emergency physician should titrate vasopressor medications to more closely match a patient's chronic perfusion pressure rather than target a mean arterial blood pressure of 65 mmHg for all critically ill patients.
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Affiliation(s)
- Michael E Winters
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Kami Hu
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Joseph P Martinez
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Haney Mallemat
- Departments of Critical Care Medicine and Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
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175
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Blaylock RL. Covid-19 pandemic: What is the truth? Surg Neurol Int 2021; 12:591. [PMID: 34992908 PMCID: PMC8720447 DOI: 10.25259/sni_1008_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/27/2021] [Indexed: 12/12/2022] Open
Abstract
The ongoing “pandemic” involving the severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2) has several characteristics that make it unique in the history of pandemics. This entails not only the draconian measures that some countries and individual states within the United States and initiated and made policy, most of which are without precedent or scientific support, but also the completely unscientific way the infection has been handled. For the 1st time in medical history, major experts in virology, epidemiology, infectious diseases, and vaccinology have not only been ignored, but are also demonized, marginalized and in some instances, become the victim of legal measures that can only be characterized as totalitarian. Discussions involving various scientific opinions have been eliminated, top scientists have been frightened into silence by threats to their careers, physicians have lost their licenses, and the concept of early treatment has been virtually eliminated. Hundreds of thousands of people have died needlessly as a result of, in my opinion and the opinion of others, poorly designed treatment protocols, mostly stemming from the Center for Disease Control and Prevention, which have been rigidly enforced among all hospitals. The economic, psychological, and institutional damage caused by these unscientific policies is virtually unmeasurable. Whole generations of young people will suffer irreparable damage, both physical and psychological, possibly forever. The truth must be told.
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Healey KD, Rifai SM, Rifai AO, Edmond M, Baker DS, Rifai K. Edwardsiella tarda: A Classic Presentation of a Rare Fatal Infection, with Possible New Background Risk Factors. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e934347. [PMID: 34873141 PMCID: PMC8667629 DOI: 10.12659/ajcr.934347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Patient: Female, 59-year-old
Final Diagnosis: Sepsis
Symptoms: Acute kidney injury • pancytopenia • respiratory deterioration • sepsis
Medication: —
Clinical Procedure: Mechanical ventilation
Specialty: Critical Care Medicine • Infectious Diseases
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Affiliation(s)
- Kevin D Healey
- Department of Research and Education, Lake Erie College of Osteopathic Medicine, Bradenton, FL, USA
| | - Sami M Rifai
- Department of Research and Education, Hypertension Kidney and Dialysis Specialists, Panama City, FL, USA
| | - Ahmad Oussama Rifai
- Department of Education and Publications, The Virtual Nephrologist, Inc., Lynn Haven, FL, USA
| | - Masha Edmond
- Gulf Coast Regional Medical Center, Panama City, FL, USA
| | - Daniel S Baker
- Gulf Coast Regional Medical Center, Panama City, FL, USA
| | - Kareem Rifai
- Department of Research and Education, Alabama College of Osteopathic Medicine, Dothan, AL, USA
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177
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Kassem AB, Ahmed I, Omran G, Megahed M, Habib T. Role of AScorbic acid Infusion in critically ill patients with Transfusion Related Acute Lung Injury (ASTRALI). Br J Clin Pharmacol 2021; 88:2327-2339. [PMID: 34866234 DOI: 10.1111/bcp.15167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION In critically ill patients, Transfusion Related Acute Lung Injury (TRALI) remains the leading cause of transfusion-related fatalities in critical care setting and associated with inflammation and oxidative stress state. Recent research raised the potential efficacy of high dose intravenous ascorbic acid in critically ill patients. OBJECTIVE The aim of this trial was to investigate the effect of high dose intravenous ascorbic acid (VC) as a targeted therapy for TRALI in terms of serum proinflammatory (interleukin-8, interleukin-1β, C-reactive protein), anti-inflammatory (interleukin-10), oxidative stress (superoxide dismutase, malondialdehyde) markers, and plasma VC levels. Secondary outcomes were oxygenation (PaO2 /FiO2 ratio), vasopressor use, duration of mechanical ventilation, ICU length of stay, 7-days mortality and 28-days mortality. METHODS Eighty critically ill patients with TRALI (n=80) were randomized to receive 2.5gm/6hr intravenous vitamin C for 96 hours (ASTRALI group) or placebo. Patients were followed-up to measure the outcomes initially (T0) and at the end of treatment (T96). RESULTS When compared to control group, ASTRALI group at T96, showed significantly higher median of interleukin-10 (31.6 ± 25.8 Vs. 17.7 ± 12.0 pg/mL, p<0.0001) levels and superoxide dismutase (12876 ± 4627 U/L Vs. 5895 ± 6632 U/L, p<0.0001) activities, lower median C-reactive protein (76 ± 50 Vs. 89 ± 56 mg/L, p=0.033), interleukin-8 (11.8 ± 7.3, 35.5 ± 19.8 pg/mL, p<0.0001), and malondialdehyde (0.197 ± 0.034 Vs. 0.234 ± 0.074 μM/L, p=0.002) levels. CONCLUSION High dose ascorbic acid was associated with significantly reduced oxidative stress, reduced pro-inflammatory markers except IL-1β, elevated anti-inflammatory marker, and elevated plasma VC levels.
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Affiliation(s)
- Amira B Kassem
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Damanhour University, Egypt
| | - Islam Ahmed
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Damanhour University, Egypt
| | - Gamal Omran
- Biochemistry Department, Faculty of Pharmacy, Damanhour University, Egypt
| | - Mohamed Megahed
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Egypt
| | - Tamer Habib
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Egypt
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The Effects of Vitamin C on the Multiple Pathophysiological Stages of COVID-19. Life (Basel) 2021; 11:life11121341. [PMID: 34947872 PMCID: PMC8708699 DOI: 10.3390/life11121341] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 12/22/2022] Open
Abstract
Currently available anti-viral drugs may be useful in reducing the viral load but are not providing the necessary physiological effects to reduce the SARS-CoV-2 complications efficiently. Treatments that provide better clinical outcomes are urgently needed. Vitamin C (ascorbic acid, AA) is an essential nutrient with many biological roles that have been proven to play an important part in immune function; it serves as an antioxidant, an anti-viral, and exerts anti-thrombotic effects among many other physiological benefits. Research has proven that AA at pharmacological doses can be beneficial to patients with acute respiratory distress syndrome (ARDS) and other respiratory illnesses, including sepsis. In addition, High-Dose Intravenous Vitamin C (HDIVC) has proven to be effective in patients with different viral diseases, such as influenza, chikungunya, Zika, and dengue. Moreover, HDIVC has been demonstrated to be very safe. Regarding COVID-19, vitamin C can suppress the cytokine storm, reduce thrombotic complications, and diminish alveolar and vascular damage, among other benefits. Due to these reasons, the use of HDIVC should be seriously considered in complicated COVID-19 patients. In this article, we will emphasize vitamin C’s multiple roles in the most prominent pathophysiological processes presented by the COVID-19 disease.
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Bissell BD, Campbell J, Collins R, Cook C, Desai D, DeWitt J, Eche IM, Eche IJ, Elsamadisi P, Juul J, Kim S, Makowski CT, Mylvaganam RJ, Smith A, Stancati J, Stonesifer K, Tawil J, Smith Condeni M. Major Publications in the Critical Care Pharmacotherapy Literature: 2020. Crit Care Explor 2021; 3:e0590. [PMID: 34909697 PMCID: PMC8663877 DOI: 10.1097/cce.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2020. DATA SOURCES The Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update group screened 36 journals monthly for impactful publications. STUDY SELECTION The group reviewed a total of 119 articles during 2020 according to relevance for practice. DATA EXTRACTION Articles were selected with consensus and importance to clinical practice from those included in the monthly Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update. The group reviewed articles according to Grading of Recommendations, Assessment, Development, and Evaluations criteria. Articles with a 1A grade were selected. DATA SYNTHESIS Several trials were summarized, including two meta-analyses and five original research trials. Original research trials evaluating vitamin C, hydrocortisone, and thiamine versus hydrocortisone in sepsis, the use of nonsedation strategies, dexmedetomidine in cardiac surgery, remdesivir for severe acute respiratory syndrome coronavirus 2, and thrombectomy in acute ischemic stroke. Two meta-analyses determining the impact of norepinephrine initiation in patients with septic shock and the use of corticosteroids in severe acute respiratory syndrome coronavirus 2 was included. CONCLUSIONS This clinical review provides summary and perspectives of clinical practice impact on influential critical care pharmacotherapy publications in 2020.
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Affiliation(s)
| | | | - Reagan Collins
- Clinical Pharmacy Specialist in Critical Care and Nutrition Support, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles Cook
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | | | - Janelle Juul
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI
| | | | | | | | - Adam Smith
- OhioHealth Riverside Methodist Hospital, Columbus, OH
| | | | | | - Justin Tawil
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI
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Wu T, Hu C, Huang W, Xu Q, Hu B, Li J. Effect of Combined Hydrocortisone, Ascorbic Acid and Thiamine for Patients with Sepsis and Septic Shock: A Systematic Review and Meta-Analysis. Shock 2021; 56:880-889. [PMID: 34529397 DOI: 10.1097/shk.0000000000001781] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This study aims to assess the effect of HAT therapy on patients with sepsis and septic shock. METHODS We searched PubMed, Embase, and Cochrane Library for studies on HAT therapy published up to November 11, 2020. The primary outcome was the duration of vasopressor use. Secondary outcomes were change of Sequential Organ Failure Assessment (SOFA) score within 72 h; death within intensive care unit (ICU), hospital, and 28 or 30 days; length of stay in ICU and hospital; rate of procalcitonin (PCT) clearance and incidence of adverse events. We also used trial sequential analysis (TSA) to assess the reliability of the available evidence. RESULTS Six randomized controlled trials (RCTs) and seven observational studies enrolling 1,559 patients were included (762 were treated with HAT, and 797 were treated with hydrocortisone alone, standard care or placebo). HAT therapy was associated with significant reductions in duration of vasopressor use (mean differences [MD], -14.68, [95% CI, -24.28 to -5.08], P = 0.003) in RCTs, but not in observational studies (MD, 11.21 [95% CI, -44.93 to 67.35], P = 0.70). HAT therapy was associated with less organ dysfunction at 72 h both in RCTs (MD, -0.86 [95% CI, -1.32 to -0.40], P < 0.001) and observational studies (MD, -2.65 [95% CI, -5.29 to -0.01], P = 0.05). HAT therapy was associated with lower hospital mortality and higher PCT clearance in observational studies. Similar results for the primary outcome were found in the sensitivity analysis. TSA results suggested more trials to reach the required information size. CONCLUSION Among patients with sepsis and septic shock, a combination therapy of hydrocortisone, ascorbic acid, and thiamine, compared with placebo, could reduce the duration of vasopressor use and SOFA scores during the first 72 h. TRIAL REGISTRATION PROSPERO registration ID for this study is CRD42020170648 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170648).
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Affiliation(s)
- Tong Wu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Weipeng Huang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Qiancheng Xu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Jianguo Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
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Thiamine, Ascorbic Acid, and Hydrocortisone As a Metabolic Resuscitation Cocktail in Sepsis: A Meta-Analysis of Randomized Controlled Trials With Trial Sequential Analysis. Crit Care Med 2021; 49:2112-2120. [PMID: 34582409 DOI: 10.1097/ccm.0000000000005262] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Sepsis is a common condition in the ICU. Despite much research, its prognosis remains poor. In 2017, a retrospective before/after study reported promising results using a combination of thiamine, ascorbic acid, and hydrocortisone called "metabolic resuscitation cocktail" and several randomized controlled trials assessing its effectiveness were performed. DESIGN We conducted a systematic review and meta-analysis of randomized controlled trials in septic ICU patients to assess the effects of this combination therapy. SETTING PubMed, Embase, and the Cochrane library databases were searched from inception to March of 2021. Data were extracted independently by two authors. The main outcome was the change in Sequential Organ Failure Assessment score within 72 hours. Secondary outcomes included renal composite endpoints (acute kidney injury) Kidney Disease - Improving Global Outcome organization stage 3 or need for renal replacement therapy, vasopressor duration, and 28-day mortality. SUBJECTS We included randomized controlled trials with patients admitted to the ICU with sepsis or septic shock. INTERVENTION The trials compared a combination of thiamine, ascorbic acid, and hydrocortisone to standard care or placebo in patients admitted to ICU with sepsis or septic shock. MEASUREMENTS AND MAIN RESULTS We included eight randomized controlled trials (n = 1,335 patients). Within 72 hours, the median of mean improvement was -1.8 and -3.2 in the control and intervention groups, respectively (eight randomized controlled trials, n = 1,253 patients); weighted mean difference -0.82 (95% CI, -1.15 to -0.48). Data were homogeneous and the funnel plot did not suggest any publication bias. Duration of vasopressor requirement was significantly reduced in the intervention group (six randomized controlled trials). There was no evidence of a difference regarding the ICU mortality and the renal composite outcome (acute kidney injury KDIGO 3 or need for renal replacement therapy, seven randomized controlled trials). CONCLUSIONS Metabolic resuscitation cocktail administrated in ICU septic patients improves change in Sequential Organ Failure Assessment score within 72 hours. However, this improvement is modest and its clinical relevance is questionable. The impact on renal failure and mortality remains unclear.
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182
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Sato R, Hasegawa D, Prasitlumkum N, Ueoka M, Nishida K, Takahashi K, Nasu M, Dugar S. Effect of IV High-Dose Vitamin C on Mortality in Patients With Sepsis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2021; 49:2121-2130. [PMID: 34495877 DOI: 10.1097/ccm.0000000000005263] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials to investigate whether IV high-dose vitamin C improves the short-term mortality of patients with sepsis. DESIGN This study is a systematic review and meta-analysis of randomized controlled trials. We searched EMBASE, the Cochrane Central Register of Controlled Trials, and MEDLINE for randomized controlled trials that met inclusion criteria. The protocol was registered at the University hospital Medical Information Network Clinical Trials Registry (UMIN000040528). All analyses were presented with the use of random-effects models. The primary outcome was short-term mortality defined as 28-day, 30-day, or in-hospital mortality. PATIENTS Two authors independently evaluated the following eligibility criteria: 1) randomized controlled trial, 2) patients with sepsis aged ≥18 years, and 3) received intravenous high-dose vitamin C in addition to standard of care, or standard of care alone. Then, two authors independently extracted the selected patient and study characteristics and outcomes from studies that met above eligibility criteria. MEASUREMENTS AND MAIN RESULTS Eleven randomized controlled trials (n = 1,737 patients) were included in this meta-analysis. High-dose IV vitamin C was not associated with a significantly lower short-term mortality (risk ratio, 0.88; 95% CI, 0.73-1.06; p = 0.18; I2 = 29%) but was associated with a significantly shorter duration of vasopressor use (standardized mean difference, -0.35; 95% CI, -0.63 to -0.07; p < 0.01; I2 = 80%) and a significantly greater decline in the Sequential Organ Failure Assessment score at 72-96 hours (standardized mean difference, -0.20; 95% CI, -0.32 to -0.08; p < 0.01; I2 = 16%). One study reported significant association with hypernatremia, but adverse effects were rare, and high-dose vitamin C is deemed relatively safe. CONCLUSIONS In this meta-analysis, the use of IV high-dose vitamin C in patients with sepsis was not associated with lower short-term mortality although it was associated with significantly shorter duration of vasopressor use and greater decline in the Sequential Organ Failure Assessment score at 72-96 hours.
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Affiliation(s)
- Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Narut Prasitlumkum
- Department of Cardiology, University of California Riverside School of Medicine, Riverside, CA
| | - Miki Ueoka
- Department of Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI
| | - Kazuki Nishida
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Aichi, Japan
- Department of Biostatistics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Michitaka Nasu
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
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183
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Drożdżal S, Rosik J, Lechowicz K, Machaj F, Szostak B, Przybyciński J, Lorzadeh S, Kotfis K, Ghavami S, Łos MJ. An update on drugs with therapeutic potential for SARS-CoV-2 (COVID-19) treatment. Drug Resist Updat 2021; 59:100794. [PMID: 34991982 PMCID: PMC8654464 DOI: 10.1016/j.drup.2021.100794] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 02/07/2023]
Abstract
The COVID-19 pandemic is one of the greatest threats to human health in the 21st century with more than 257 million cases and over 5.17 million deaths reported worldwide (as of November 23, 2021. Various agents were initially proclaimed to be effective against SARS-CoV-2, the etiological agent of COVID-19. Hydroxychloroquine, lopinavir/ritonavir, and ribavirin are all examples of therapeutic agents, whose efficacy against COVID-19 was later disproved. Meanwhile, concentrated efforts of researchers and clinicians worldwide have led to the identification of novel therapeutic options to control the disease including PAXLOVID™ (PF-07321332). Although COVID-19 cases are currently treated using a comprehensive approach of anticoagulants, oxygen, and antibiotics, the novel Pfizer agent PAXLOVID™ (PF-07321332), an investigational COVID-19 oral antiviral candidate, significantly reduced hospitalization time and death rates, based on an interim analysis of the phase 2/3 EPIC-HR (Evaluation of Protease Inhibition for COVID-19 in High-Risk Patients) randomized, double-blind study of non-hospitalized adult patients with COVID-19, who are at high risk of progressing to severe illness. The scheduled interim analysis demonstrated an 89 % reduction in risk of COVID-19-related hospitalization or death from any cause compared to placebo in patients treated within three days of symptom onset (primary endpoint). However, there still exists a great need for the development of additional treatments, as the recommended therapeutic options are insufficient in many cases. Thus far, mRNA and vector vaccines appear to be the most effective modalities to control the pandemic. In the current review, we provide an update on the progress that has been made since April 2020 in clinical trials concerning the effectiveness of therapies available to combat COVID-19. We focus on currently recommended therapeutic agents, including steroids, various monoclonal antibodies, remdesivir, baricitinib, anticoagulants and PAXLOVID™ summarizing the latest original studies and meta-analyses. Moreover, we aim to discuss other currently and previously studied agents targeting COVID-19 that either show no or only limited therapeutic activity. The results of recent studies report that hydroxychloroquine and convalescent plasma demonstrate no efficacy against SARS-CoV-2 infection. Lastly, we summarize the studies on various drugs with incoherent or insufficient data concerning their effectiveness, such as amantadine, ivermectin, or niclosamide.
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Affiliation(s)
- Sylwester Drożdżal
- Department of Nephrology, Transplantation and Internal Medicine, Pomeranian Medical University in Szczecin, Poland
| | - Jakub Rosik
- Department of Physiology, Pomeranian Medical University in Szczecin, Poland
| | - Kacper Lechowicz
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland
| | - Filip Machaj
- Department of Physiology, Pomeranian Medical University in Szczecin, Poland
| | - Bartosz Szostak
- Department of Physiology, Pomeranian Medical University in Szczecin, Poland
| | - Jarosław Przybyciński
- Department of Nephrology, Transplantation and Internal Medicine, Pomeranian Medical University in Szczecin, Poland
| | - Shahrokh Lorzadeh
- Department of Molecular Genetics, Science and Research Branch, Marvdasht Branch, Islamic Azad University, Marvdasht, Iran
| | - Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland
| | - Saeid Ghavami
- Department of Human Anatomy and Cell Science, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Research Institutes of Oncology and Hematology, Cancer Care Manitoba-University of Manitoba, Winnipeg, MB R3E 0V9, Canada; Biology of Breathing Theme, Children Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB R3E 0V9, Canada; Autophagy Research Center, Shiraz University of Medical Sciences, Shiraz 7134845794, Iran; Faculty of Medicine, Katowice School of Technology, 40-555 Katowice, Poland
| | - Marek J Łos
- Biotechnology Centre, Silesian University of Technology, 44-100 Gliwice, Poland.
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184
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McCune TR, Toepp AJ, Sheehan BE, Sherani MSK, Petr ST, Dodani S. High dose intravenous vitamin C treatment in Sepsis: associations with acute kidney injury and mortality. BMC Nephrol 2021; 22:387. [PMID: 34800992 PMCID: PMC8606062 DOI: 10.1186/s12882-021-02599-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 11/03/2021] [Indexed: 01/02/2023] Open
Abstract
Background The effects of vitamin C on clinical outcomes in critically ill patients remain controversial due to inconclusive studies. This retrospective observational cohort study evaluated the effects of vitamin C therapy on acute kidney injury (AKI) and mortality among septic patients. Methods Electronic medical records of 1390 patients from an academic hospital who were categorized as Treatment (received at least one dose of 1.5 g IV vitamin C, n = 212) or Comparison (received no, or less than 1.5 g IV vitamin C, n = 1178) were reviewed. Propensity score matching was conducted to balance a number of covariates between groups. Multivariate logistic regressions were conducted predicting AKI and in-hospital mortality among the full sample and a sub-sample of patients seen in the ICU. Results Data revealed that vitamin C therapy was associated with increases in AKI (OR = 2.07 95% CI [1.46–2.93]) and in-hospital mortality (OR = 1.67 95% CI [1.003–2.78]) after adjusting for demographic and clinical covariates. When stratified to examine ICU patients, vitamin C therapy remained a significant risk factor of AKI (OR = 1.61 95% CI [1.09–2.39]) and provided no protective benefit against mortality (OR = 0.79 95% CI [0.48–1.31]). Conclusion Ongoing use of high dose vitamin C in sepsis should be appraised due to observed associations with AKI and death.
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Affiliation(s)
- Thomas R McCune
- Division of Nephrology, Department of Internal Medicine, Eastern Virginia Medical School, 301 Riverview Ave, Suite 600, Norfolk, Virginia, 23510, USA.
| | - Angela J Toepp
- EVMS-Sentara Healthcare Analytics and Delivery Science Institute, Eastern Virginia Medical School, Norfolk, Virginia, USA.,Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Brynn E Sheehan
- EVMS-Sentara Healthcare Analytics and Delivery Science Institute, Eastern Virginia Medical School, Norfolk, Virginia, USA.,Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | | | | | - Sunita Dodani
- EVMS-Sentara Healthcare Analytics and Delivery Science Institute, Eastern Virginia Medical School, Norfolk, Virginia, USA.,Division of Cardiology, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
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185
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Davis J, Umeh U, Saba R. Treatment of SARS-CoV-2 (COVID-19): A safety perspective. World J Pharmacol 2021; 10:1-32. [DOI: 10.5497/wjp.v10.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/22/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
The goal of this review is to report a balanced perspective of current evidence for efficacy of treatments for coronavirus disease 2019 (COVID-19) against the historical safety of these treatments as of May 2021. We preselected therapies of interest for COVID-19 based on national guidelines and modified over time. We searched PubMed and Medline for these specific COVID-19 treatments and data related to their efficacy. We also searched for prior randomized controlled trials of each therapy to assess adverse effects, and we obtained the Food and Drug Administration Approval label for this information. Several drugs have been approved for the treatment of COVID-19, and many more are under study. This includes dexamethasone, remdesivir, hydroxychloroquine/chloroquine, lopinvir/ritonavir, interferon or interleukin inhibitors, convalescent plasma and several vitamins and minerals. The strongest evidence for benefit is mortality benefit with dexamethasone in patients with COVID-19 and hypoxemia, although there is a signal of harm if this is started too early. There are several other promising therapies, like interleukin inhibitors and ivermectin. Hydroxychloroquine/chloroquine, lopinvir/ritonavir, and convalescent plasma do not have enough evidence of benefit to outweigh the known risks of these drugs.
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Affiliation(s)
- Joshua Davis
- Department of Emergency Medicine, Vituity, Wichita, KS 67214, United States
| | - Ugochukwu Umeh
- College of Medicine, Medical University of Lublin, Lublin 20-093, Poland
| | - Rand Saba
- Department of Surgery, Ascension Providence Hospital, Southfield, MI 48075, United States
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186
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Joffre J, Hellman J. Oxidative Stress and Endothelial Dysfunction in Sepsis and Acute Inflammation. Antioxid Redox Signal 2021; 35:1291-1307. [PMID: 33637016 DOI: 10.1089/ars.2021.0027] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Significance: Under homeostatic conditions, the endothelium dynamically regulates vascular barrier function, coagulation pathways, leukocyte adhesion, and vasomotor tone. During sepsis and acute inflammation, endothelial cells (ECs) undergo multiple phenotypic and functional modifications that are initially adaptive but eventually become harmful, leading to microvascular dysfunction and multiorgan failure. Critical Issues and Recent Advances: Sepsis unbalances the redox homeostasis toward a pro-oxidant state, characterized by an excess production of reactive oxygen species and reactive nitrogen species, mitochondrial dysfunction, and a breakdown of antioxidant systems. In return, oxidative stress (OS) alters multiple EC functions and promotes a proinflammatory, procoagulant, and proadhesive phenotype. The OS also induces glycocalyx deterioration, cell death, increased permeability, and impaired vasoreactivity. Thus, during sepsis, the ECs are both a significant source and one of the main targets of OS. Future Directions: This review aims at covering the current understanding of the role of OS in the endothelial adaptive or maladaptive multifaceted response to sepsis and to outline the therapeutic potential and issues of targeting OS and endothelial dysfunction during sepsis and septic shock. One of the many challenges in the management of sepsis is now based on the detection and correction of these anomalies of endothelial function.
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Affiliation(s)
- Jérémie Joffre
- Department of Anesthesia and Perioperative Care, University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco School of Medicine, San Francisco, California, USA
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187
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Krishnan K, Wassermann TB, Tednes P, Bonderski V, Rech MA. Beyond the bundle: Clinical controversies in the management of sepsis in emergency medicine patients. Am J Emerg Med 2021; 51:296-303. [PMID: 34785486 DOI: 10.1016/j.ajem.2021.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 01/21/2023] Open
Abstract
Sepsis is a condition characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection. The emergency department (ED) serves as a crucial entry point for patients presenting with sepsis. Given the heterogeneous presentation and high mortality rate associated with sepsis and septic shock, several clinical controversies have emerged in the management of sepsis. These include the use of novel therapeutic agents like angiotensin II, hydrocortisone, ascorbic acid, thiamine ("HAT") therapy, and levosimendan, Additionally, controversies with current treatments in vasopressor dosing, and the use of and balanced or unbalanced crystalloid are crucial to consider. The purpose of this review is to discuss clinical controversies in the management of septic patients, including the use of novel medications and dosing strategies, to assist providers in appropriately determining what treatment strategy is best suited for patients.
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Affiliation(s)
- Kavita Krishnan
- Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, 60153, United States of America
| | - Travis B Wassermann
- Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, 60153, United States of America
| | - Patrick Tednes
- Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, 60153, United States of America; Department of Pharmacy, Loyola University Medical Center, Maywood, IL, 60153, United States of America
| | - Veronica Bonderski
- Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, 60153, United States of America; Department of Pharmacy, Loyola University Medical Center, Maywood, IL, 60153, United States of America
| | - Megan A Rech
- Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, 60153, United States of America; Department of Pharmacy, Loyola University Medical Center, Maywood, IL, 60153, United States of America.
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188
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The Role of Herbal and Nutritional Treatments in the Fight against COVID-19 and Other Respiratory Tract Infections. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212001. [PMID: 34831757 PMCID: PMC8624644 DOI: 10.3390/ijerph182212001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 09/29/2021] [Accepted: 10/12/2021] [Indexed: 12/17/2022]
Abstract
With the growing spread of COVID-19 worldwide, the appeal to alternative and nutritional therapies in conjunction with medical therapies has been heightened. This article aims to review studies assessing the roles of Chinese traditional medicine and nutrition in upper respiratory infections, including COVID-19. Various Chinese herbal protocols have been shown to fight respiratory infections, with several having been tested on the novel coronavirus. Additionally, promising findings have been reported when medical treatments were complemented with nutritional interventions. Supplementation with vitamins C and D, Zinc and Selenium are discussed, in addition to certain phytochemicals and food that also possess immunoregulatory and antiviral properties. Further clinical studies are needed to establish these alternative treatments as part of the management of emerging respiratory infections.
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189
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Gao L, Chong E, Pendharkar S, Phillips A, Ke L, Li W, Windsor JA. The Challenges and Effects of Ascorbic Acid Treatment of Acute Pancreatitis: A Systematic Review and Meta-Analysis of Preclinical and Clinical Studies. Front Nutr 2021; 8:734558. [PMID: 34765629 PMCID: PMC8576576 DOI: 10.3389/fnut.2021.734558] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/22/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Oxidative stress has been implicated in the pathogenesis of acute pancreatitis (AP), and ascorbic acid (AA), as an important endogenous antioxidant substance, has been shown to reduce AP severity in preclinical studies. However, the effects of AA supplementation in clinical settings remain controversial. Methods: PubMed, EMBASE, MEDLINE, and SCOPUS databases were searched, and both preclinical and clinical studies were included. For clinical trials, the primary outcome was incidence of organ failure, and for preclinical studies, the primary outcome was histopathological scores of pancreatic injuries. Results: Meta-analysis of clinical trials showed that compared with controls, AA administration did not reduce the incidence of organ failure or mortality during hospitalization but was associated with significantly reduced length of hospital stay. Meta-analysis of preclinical studies showed that AA supplementation reduced pancreatic injury, demonstrated as decreased histological scores and serum amylase, lipase levels. Conclusion: AA administration has no effect on survival or organ failure in patients with AP but may reduce the length of hospital stay. However, the evidence to date remains sparse, scattered, and of suboptimal quality, making it difficult to draw any firm conclusion on the clinical benefits of AA in AP.
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Affiliation(s)
- Lin Gao
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Eric Chong
- Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Sayali Pendharkar
- Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Anthony Phillips
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Lu Ke
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Weiqin Li
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - John Albert Windsor
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, School of Medicine, University of Auckland, Auckland, New Zealand
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190
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Vandervelden S, Wauters L, Breuls J, Fieuws S, Vanhove P, Hubloue I, Bartiaux M, Creteur J, Stifkens F, Monsieurs K, Desruelles D. Early administration of Vitamin C in patients with sepsis or septic shock in emergency departments: A multicenter, double blinded, randomized controlled trial: The C-EASIE trial protocol. PLoS One 2021; 16:e0259699. [PMID: 34739527 PMCID: PMC8570477 DOI: 10.1371/journal.pone.0259699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Sepsis is a potentially life-threatening condition characterized by a deregulated body's response to infection causing injury to its own tissues and organs. Sepsis is the primary cause of death from infection. If not recognized and treated timely, it can evolve within minutes/hours to septic shock. Sepsis is associated with an acute deficiency of Vitamin C. Despite the proof-of-concept of the benefit of administering Vitamin C in patients with sepsis or septic shock, Vitamin C administration is not yet current practice. OBJECTIVE To investigate the potential benefit of early administration of high doses of Vitamin C in addition to standard of care in patients with sepsis or septic shock. METHODS This phase 3b multi-center trial is conducted in 8 hospitals throughout Belgium. In total 300 patients will be randomly assigned to one of two groups in a 1:1 allocation ratio. The intervention group will receive 1.5 g Vitamin C 4 times a day during 4 days, started within 6 hours after admission. The primary outcome is the average post-baseline patient SOFA score. CONCLUSION This trial will determine whether the early administration of Vitamin C in patients with sepsis or septic shock can lead to a more rapid solution of shock and less deterioration from sepsis to septic shock, hereby reducing morbidity and mortality as well as the length of hospital stay in this patient population. TRIAL REGISTRATION The C-EASIE trial has been registered on the ClinicalTrials.gov website on 10 February 2021 with registration number NCT04747795. TRIAL SPONSOR UZ Leuven (sponsor's reference S63213).
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Affiliation(s)
| | - Lina Wauters
- Department of Emergency Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jan Breuls
- Department of Emergency Medicine, Algemeen Ziekenhuis Turnhout, Rubensstraat, Turnhout, Belgium
| | - Steffen Fieuws
- Leuven Biostatistics and Statistical Bioinformatics Center (L-BioStat), Kapucijnenvoer, Leuven, Belgium
| | - Philippe Vanhove
- Department of Intensive Care, GZA Ziekenhuizen, Antwerpen, Belgium
| | - Ives Hubloue
- Department of Emergency Medicine, University Hospitals Brussel, Jette, Belgium
| | - Magali Bartiaux
- Department of Emergency Medicine, University Medical Center Saint Pierre, Bruxelles, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital Brussels, Bruxelles, Belgium
| | - François Stifkens
- Department of Emergency Medicine, Center Hospitalier Universitaire de Liège, Liège, Belgium
| | - Koen Monsieurs
- Department of Emergency Medicine, University Hospitals Antwerp, Edegem, Belgium
| | - Didier Desruelles
- Department of Emergency Medicine, University Hospitals Leuven, Leuven, Belgium
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191
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 907] [Impact Index Per Article: 302.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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192
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Park J, Kang E, Kang S, Kim D, Kim D, Park SJ, Jhang WK. Mitochondrial gene mutations in pediatric septic shock. Pediatr Res 2021; 90:1016-1022. [PMID: 33504965 DOI: 10.1038/s41390-020-01358-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND There has been a growing interest in the association between mitochondrial dysfunction and sepsis. However, most studies have focused on mitochondrial structural damage, functional aspects, or the clinical phenotypes in sepsis. The purpose of this study was to evaluate mitochondrial DNA (mtDNA) gene mutations in critically ill pediatric patients with septic shock. METHOD Thirteen patients with severe sepsis or septic shock admitted to the pediatric intensive care unit (PICU) of a tertiary children's hospital were enrolled in this prospective observational study. Clinical data from electronic medical records were obtained. Whole-blood samples were collected within 24 h of PICU admission to perform PBMC isolation, mtDNA extraction, and mtDNA sequencing using next-generation sequencing. RESULTS mtDNA sequencing revealed mutations in 9 of the 13 patients, presenting 27 point mutations overall, with 15 (55.6%) located in the locus related to adenosine triphosphate production and superoxide metabolism, including electron transport. CONCLUSION In this pilot study, significant numbers of mtDNA point mutations were detected in critically ill pediatric patients with septic shock. These mutations could provide promising evidence for mitochondrial dysfunction in sepsis and a basis for further large-scale studies. IMPACT This study is the first to examine mitochondrial DNA mutations in pediatric patients with septic shock using next-generation sequencing. A high frequency of mitochondrial DNA mutations was detected in these patients indicating an association with septic shock. This pilot study may provide a potential explanation for the association between mitochondrial dysfunction and septic shock on a genetic basis.
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Affiliation(s)
- Junsung Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eunju Kang
- Department of Convergence Medicine and Stem Cell Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seoon Kang
- Department of Convergence Medicine and Stem Cell Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Deokhoon Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dahyun Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong Jong Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Kyoung Jhang
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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193
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Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:1974-1982. [PMID: 34643578 DOI: 10.1097/ccm.0000000000005357] [Citation(s) in RCA: 197] [Impact Index Per Article: 65.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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194
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Wentowski C, Ingles DP, Nielsen ND. Sepsis 2021: a review. ANAESTHESIA & INTENSIVE CARE MEDICINE 2021. [DOI: 10.1016/j.mpaic.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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195
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Behrad Nasab M, Akbari ME, Rastgoo S, Gholami S, Hajipour A, Majidi N, Gholamalizadeh M, Mirzaei Dahka S, Doaei S, Goodarzi MO. Comparison of Biochemical and Pathological Parameters and Parenteral Nutrition of ICU Patients Under Supervision of Dietitians and Surgeons. Front Nutr 2021; 8:729510. [PMID: 34692745 PMCID: PMC8528958 DOI: 10.3389/fnut.2021.729510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/13/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Nutrient imbalance can frequently occur in patients with indications for parenteral nutrition (PN) after gastrointestinal surgery. This study aimed to compare the recommendations of a surgeon to those of a dietitian in the field of parenteral nutrition. Methods: This study was performed on 256 patients undergoing gastrointestinal surgery who received PN, which included 120 patients who received PN based on recommendations of the surgeons and 136 patients who were referred to receive PN under the supervision of a dietitian in Razi Hospital in Rasht, Iran. Data on PN and clinical outcomes of the patients were collected. Results: Patients under the supervision of dietitians received higher vitamin B complex and lipids and lower vitamin A and vitamin E than the surgeon-supervised patients (all P < 0.001). In the group receiving PN under the supervision of a surgeon, the level of blood glucose (207 vs. 182, P < 0.01), sodium (138 vs. 136, P = 0.01), potassium (3.97 vs. 3.53, P < 0.01), and white blood cell count (9.83 vs. 9.28, P < 0.01) increased significantly at the end of the PN compared to baseline. In the group receiving PN under the supervision of a dietician, the level of serum Cr (1.23 vs. 1.32, P = 0.04), Mg (2.07 vs. 1.84, P < 0.01), and pH (7.45 vs. 7.5, P = 0.03) significantly improved after receiving parenteral nutrition compared to baseline. Conclusion: The amounts of nutrients recommended for PN by the surgeon and dietitian were different. Implementation of dietitian recommendations in critically ill patients under PN can improve patients' clinical parameters.
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Affiliation(s)
- Mojgan Behrad Nasab
- Department of Physical Education and Sport Sciences, Faculty of Sport Science, Central Tehran Branch, Islamic Azad University, Tehran, Iran
| | | | - Samira Rastgoo
- Department of Clinical Nutrition and Dietetics, Research Institute Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Somayeh Gholami
- Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Azadeh Hajipour
- Department of Health Sciences in Nutrition, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Nazanin Majidi
- Department of Nutrition, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Maryam Gholamalizadeh
- Student Research Committee, Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Saied Doaei
- Reproductive Health Research Center, School of Health, Guilan University of Medical Sciences, Rasht, Iran
| | - Mark O Goodarzi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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196
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Yang X, You J, Wei Y, Li H, Gao L, Guo Q, Huang Y, Gong C, Yi C. Emerging nanomaterials applied for tackling the COVID-19 cytokine storm. J Mater Chem B 2021; 9:8185-8201. [PMID: 34528037 DOI: 10.1039/d1tb01446c] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
During the global outbreak of coronavirus disease 2019 (COVID-19), a hyperinflammatory state called the cytokine storm was recognized as a major contributor to multiple organ failure and mortality. However, to date, the diagnosis and treatment of the cytokine storm remain major challenges for the clinical prognosis of COVID-19. In this review, we outline various nanomaterial-based strategies for preventing the COVID-19 cytokine storm. We highlight the contribution of nanomaterials to directly inhibit cytokine release. We then discuss how nanomaterials can be used to deliver anti-inflammatory drugs to calm the cytokine storm. Nanomaterials also play crucial roles in diagnostics. Nanomaterial-based biosensors with improved sensitivity and specificity can be used to detect cytokines. In summary, emerging nanomaterials offer platforms and tools for the detection and treatment of the COVID-19 cytokine storm and future pandemic.
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Affiliation(s)
- Xi Yang
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Jia You
- Department of Oncology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yuanfeng Wei
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Huawei Li
- Department of Oncology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ling Gao
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Qing Guo
- Department of Oncology, Taizhou People's Hospital, Taizhou, China
| | - Ying Huang
- West China School of Basic Medical Science and Forensic Medicine, Sichuan University, Chengdu, China
| | - Changyang Gong
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Cheng Yi
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
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197
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Vitamin C in Critically Ill Patients: An Updated Systematic Review and Meta-Analysis. Nutrients 2021; 13:nu13103564. [PMID: 34684565 PMCID: PMC8539952 DOI: 10.3390/nu13103564] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Vitamin C is a water-soluble antioxidant vitamin. Oxidative stress and its markers, along with inflammatory markers, are high during critical illness. Due to conflicting results of the published literature regarding the efficacy of vitamin C in critically ill patients, and especially the concerns for nephrotoxicity raised by some case reports, this meta-analysis was carried out to appraise the evidence and affirmation regarding the role of vitamin C in critically ill patients. Methods: We searched the database thoroughly to collect relevant studies that assessed intravenous vitamin C use in critically ill patients published until 25 February 2021. We included randomized controlled trials and observational studies with 20 or more critically ill patients who have received intravenous ascorbic acid (vitamin C). After screening 18,312 studies from different databases, 53 were included in our narrative synthesis, and 48 were included in the meta-analysis. We used the Covidence software for screening of the retrieved literature. Review Manager (RevMan) 5.4 was used for the pooling of data and Odds Ratios (OR) and Mean difference (MD) as measures of effects with a 95% confidence interval to assess for explanatory variables. Results: Pooling data from 33 studies for overall hospital mortality outcomes using a random-effect model showed a 19% reduction in odds of mortality among the vitamin C group (OR, 0.81; 95% CI, 0.66–0.98). Length of hospital stay (LOS), mortality at 28/30 days, ICU mortality, new-onset AKI and Renal Replacement Therapy (RRT) for AKI did not differ significantly across the two groups. Analysis of data from 30 studies reporting ICU stay disclosed 0.76 fewer ICU days in the vitamin C group than the placebo/standard of care (SOC) group (95% CI, −1.34 to −0.19). This significance for shortening ICU stay persisted even when considering RCTs only in the analysis (MD, −0.70; 95% CI, −1.39 to −0.02). Conclusion: Treatment of critically ill patients with intravenous vitamin C was relatively safe with no significant difference in adverse renal events and decreased in-hospital mortality. The use of vitamin C showed a significant reduction in the length of ICU stays in critically ill patients.
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198
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Vincent JL, Ince C, Pickkers P. Endothelial dysfunction: a therapeutic target in bacterial sepsis? Expert Opin Ther Targets 2021; 25:733-748. [PMID: 34602020 DOI: 10.1080/14728222.2021.1988928] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Endothelial cells maintain vascular integrity, tone, and patency and have important roles in hemostasis and inflammatory responses. Although some degree of endothelial dysfunction with increased vascular permeability may be necessary to control local infection, excessive dysfunction plays a central role in the pathogenesis of sepsis-related organ dysfunction and failure as it results in dysregulated inflammation, vascular leakage, and abnormal coagulation. The vascular endothelium has thus been proposed as a potential target for therapeutic intervention in patients with sepsis. AREAS COVERED Different mechanisms underlying sepsis-related dysfunction of the vascular endothelium are discussed, including glycocalyx shedding, nitrosative stress, and coagulation factors. Potential therapeutic implications of each mechanism are mentioned. EXPERT OPINION Multiple targets to protect or restore endothelial function have been suggested, but endothelium-driven treatments remain a future potential at present. As some endothelial dysfunction and permeability may be necessary to remove infection and repair damaged tissue, targeting the endothelium may be a particular challenge. Ideally, therapies should be guided by biomarkers related to that specific pathway to ensure they are given only to patients most likely to respond. This enrichment based on biological plausibility and theragnostics will increase the likelihood of a beneficial response in individual patients and enable more personalized treatment.
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Affiliation(s)
- Jean-Louis Vincent
- Dept of Intensive Care, Erasme Hospital, Université Libre De Bruxelles, Brussels, Belgium
| | - Can Ince
- Department of Intensive Care, Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Peter Pickkers
- Dept of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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199
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1484] [Impact Index Per Article: 494.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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200
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Nedel W, Lisboa T, Salluh JIF. What Is the Role of Steroids for Septic Shock in 2021? Semin Respir Crit Care Med 2021; 42:726-734. [PMID: 34544190 DOI: 10.1055/s-0041-1733900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Corticosteroids have been used for decades in the adjunctive treatment of severe infections in intensive care. The most frequent scenario in intensive care is in septic shock, where low doses of glucocorticoids appear to restore vascular responsiveness to norepinephrine. There is a strong body of evidence suggesting that hydrocortisone reduces time on vasopressor, and may modulate the immune response. In this review, we explore the current evidence supporting the use of corticosteroids in septic shock, its benefits, and potential harms. In addition to landmark clinical trials, we will also describe new frontiers for the use of corticosteroids in septic shock which should be explored in future studies.
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Affiliation(s)
- Wagner Nedel
- Programa de Pós-Graduação em Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Programa de Pós-Graduação em Ciencias Pneumologicas, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Universidade Unilasalle, Canoas, Brazil
- Instituto de Pesquisa, HCOR, São Paulo, Brazil
| | - Jorge I F Salluh
- Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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