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Liang C, Pan S, Wu W, Chen F, Zhang C, Zhou C, Gao Y, Ruan X, Quan S, Zhao Q, Pan J. Glucocorticoid therapy for sepsis in the AI era: a survey on current and future approaches. Comput Struct Biotechnol J 2024; 24:292-305. [PMID: 38681133 PMCID: PMC11047203 DOI: 10.1016/j.csbj.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 05/01/2024] Open
Abstract
Sepsis, a life-threatening medical condition, manifests as new or worsening organ failures due to a dysregulated host response to infection. Many patients with sepsis have manifested a hyperinflammatory phenotype leading to the identification of inflammatory modulation by corticosteroids as a key treatment modality. However, the optimal use of corticosteroids in sepsis treatment remains a contentious subject, necessitating a deeper understanding of their physiological and pharmacological effects. Our study conducts a comprehensive review of randomized controlled trials (RCTs) focusing on traditional corticosteroid treatment in sepsis, alongside an analysis of evolving clinical guidelines. Additionally, we explore the emerging role of artificial intelligence (AI) in medicine, particularly in diagnosing, prognosticating, and treating sepsis. AI's advanced data processing capabilities reveal new avenues for enhancing corticosteroid therapeutic strategies in sepsis. The integration of AI in sepsis treatment has the potential to address existing gaps in knowledge, especially in the application of corticosteroids. Our findings suggest that combining corticosteroid therapy with AI-driven insights could lead to more personalized and effective sepsis treatments. This approach holds promise for improving clinical outcomes and presents a significant advancement in the management of this complex and often fatal condition.
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Affiliation(s)
- Chenglong Liang
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Wenzhou Medical University, Wenzhou 325000, China
- School of Nursing, Wenzhou Medical University, Wenzhou 325000, China
| | - Shuo Pan
- Wenzhou Medical University, Wenzhou 325000, China
| | - Wei Wu
- School of Computer Science and Software Engineering, University of Science and Technology Liaoning, Anshan 114051, China
| | - Fanxuan Chen
- Wenzhou Medical University, Wenzhou 325000, China
- School of Biomedical Engineering, School of Ophthalmology and Optometry, Eye Hospital, Wenzhou Medical University, Wenzhou 325000, China
| | - Chengxi Zhang
- School of Materials Science and Engineering, Shandong Jianzhu University, Jinan 250101, China
| | - Chen Zhou
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yifan Gao
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Xiangyuan Ruan
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Shichao Quan
- Department of Big Data in Health Science, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Qi Zhao
- School of Computer Science and Software Engineering, University of Science and Technology Liaoning, Anshan 114051, China
| | - Jingye Pan
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou 325000, China
- Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou 325000, China
- Zhejiang Engineering Research Center for Hospital Emergency and Process Digitization, Wenzhou 325000, China
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Rivera Lemon EN, Lowe LE, Owens JE. SNaP-C: Validation of a novel, selective silver nanoparticle antioxidant capacity assay for Vitamin C content in beverages. Food Chem 2024; 457:140112. [PMID: 38905840 DOI: 10.1016/j.foodchem.2024.140112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 06/04/2024] [Accepted: 06/12/2024] [Indexed: 06/23/2024]
Abstract
A validated silver nanoparticle assay (SNaP-C) for quantitation of Vitamin C, as ascorbic acid (AA) and total AA (TAA), was applied to 31 beverages. SNaP-C assay results (LOD of 2.2 mg/L AA) were compared to AA and TAA determined by high-performance liquid chromatography with UV/Vis (LOD = 0.4 mg/L AA), and two well-known assays. All approaches were calibrated using meta-phosphoric acid stabilized AA, where the reducing agent tris(2-carboxyethyl) phosphine hydrochloride was added to convert dehydroascorbic acid to AA for determination of TAA. Statistical comparisons of these four resulting datasets were completed. SNaP-C and HPLC were not statistically significantly different (P > 0.05) for comparison of AA and TAA (mg/L) in these samples, whereas the CUPRAC and Folin-Ciocalteu assays statistically significantly overestimated values of AA and TAA content, respectively. The SNaP-C method is a novel assay that has high specificity for AA capable of quantifying TAA with addition of TCEP.
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Affiliation(s)
- Ericka N Rivera Lemon
- Department of Chemistry and Biochemistry, University of Colorado Colorado Springs, 1420 Austin Bluffs Parkway, Colorado Springs, CO 80918, USA.
| | - Luis E Lowe
- Department of Chemistry and Biochemistry, University of Colorado Colorado Springs, 1420 Austin Bluffs Parkway, Colorado Springs, CO 80918, USA
| | - Janel E Owens
- Department of Chemistry and Biochemistry, University of Colorado Colorado Springs, 1420 Austin Bluffs Parkway, Colorado Springs, CO 80918, USA.
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Chelly J, Peres N, Sboui G, Maizel J, Beuzelin M, Nigeon O, Preau S, Vong LVP, Tamion F, Lambiotte F, Deye N, Bertrand T, Behal H, Ducros L, Vinsonneau C. Early intravenous high-dose vitamin C in postcardiac arrest shock (VICEPAC): study protocol for a randomised, single-blind, open-label, multicentre, controlled trial. BMJ Open 2024; 14:e087303. [PMID: 39317492 PMCID: PMC11429356 DOI: 10.1136/bmjopen-2024-087303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024] Open
Abstract
INTRODUCTION The high incidence of morbidity and mortality associated with the post-cardiac arrest (CA) period highlights the need for novel therapeutic interventions to improve the outcome of out-of-hospital cardiac arrest (OHCA) patients admitted to the intensive care unit (ICU). The aim of this study is to assess the ability of high-dose intravenous vitamin C (Vit-C) to improve post-CA shock. METHODS AND ANALYSIS This is a single-blind, open-label, multicentre, randomised controlled trial, involving 234 OHCA patients with post-CA shock planned to be enrolled in 10 French ICUs. Patients will be randomised to receive standard-of-care (SOC) or SOC with early high-dose intravenous Vit-C administration (200 mg/kg per day, within 6 hours after return of spontaneous circulation, for 3 days). The primary endpoint is the cumulative incidence of vasopressor withdrawal at 72 hours after enrolment, with death considered as a competing event. The main secondary endpoints are neurological outcome, mortality due to refractory shock, vasopressor-free days and organ failure monitored by the sequential organ failure assessment score. ETHICS AND DISSEMINATION The study protocol was approved by a French Ethics Committee (EC) on 21 February 2023 (Comité de Protection des Personnes Ile de France 1, Paris, France). Due to the short enrolment period to avoid any delay in treatment, the EC approved the study inclusion before informed consent was obtained. As soon as possible, patient and their relative will be asked for their deferred informed consent. The data from the study will be disseminated through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT05817851.
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Affiliation(s)
- Jonathan Chelly
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon - La Seyne-sur-Mer, Toulon, Provence-Alpes-Côte d'Azu, France
- Délégation à la Recherche Clinique et à L'innovation du GHT 83, Toulon, France
| | - Noemie Peres
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon - La Seyne-sur-Mer, Toulon, Provence-Alpes-Côte d'Azu, France
| | - Ghada Sboui
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Béthune, Bethune, Nord-Pas de Calais, France
| | - Julien Maizel
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, Hauts-de-France, France
| | - Marion Beuzelin
- Intensive Care Unit, Centre Hospitalier de Dieppe, Dieppe, France
| | - Olivier Nigeon
- Intensive Care Unit, Centre Hospitalier de Lens, Lens, France
| | - Sebastien Preau
- Intensive Care Unit, CHU de Lille, Lille, Hauts-de-France, France
| | | | - Fabienne Tamion
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Rouen, Rouen, Normandie, France
| | - Fabien Lambiotte
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Valenciennes, Valenciennes, Nord-Pas de Calais, France
| | - Nicolas Deye
- Réanimation Médicale et Toxicologique, AP-HP, INSERM UMR-S 942, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Thibaut Bertrand
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon - La Seyne-sur-Mer, Toulon, Provence-Alpes-Côte d'Azu, France
| | - Hélène Behal
- Biostatistics Department, CHU de Lille, Lille, Hauts-de-France, France
| | - Laurent Ducros
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon - La Seyne-sur-Mer, Toulon, Provence-Alpes-Côte d'Azu, France
| | - Christophe Vinsonneau
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Béthune, Bethune, Nord-Pas de Calais, France
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Miranda CTCDS, Soares SD, de Oliveira WQ, Lima ADS, Neri Numa IA, Pastore GM. Unconventional Edible Plants of the Amazon: Bioactive Compounds, Health Benefits, Challenges, and Future Trends. Foods 2024; 13:2925. [PMID: 39335854 PMCID: PMC11431067 DOI: 10.3390/foods13182925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/03/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
The pursuit of an improved quality of life is a major trend in the food market. This is driving the reformulation of the industry's product portfolio, with the aim of providing nourishment while also contributing to beneficial health metabolic processes. In this context, the use of local biodiversity and the recovery of the traditional knowledge associated with the consumption of vegetables that grow spontaneously in nature emerge as more sustainable and nutritionally adequate concepts. The Amazon region is known for its abundant biodiversity, housing numerous unconventional food plants whose nutritional and biological properties remain unknown due to a lack of research. Among the different species are Xanthosoma sagittifolium, Acmella oleracea, Talinum triangulare, Pereskia bleo, Bidens bipinnata, and Costus spiralis. These species contain bioactive compounds such as apigenin, syringic acid, spilanthol, and lutein, which provide various health benefits. There are few reports on the biological effects, nutritional composition, bioactive compounds, and market prospects for these species. Therefore, this review provides an overview of their nutritional contribution, bioactive compounds, health benefits, and current market, as well as the use of new technologies that can contribute to the development of functional products/ingredients derived from them.
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Affiliation(s)
- Cynthia Tereza Corrêa da Silva Miranda
- Laboratory of Bioflavours and Bioactive Compounds, Department of Food Science, Faculty of Food Engineering, University of Campinas, Campinas 13083-862, SP, Brazil; (S.D.S.); (W.Q.d.O.); (A.d.S.L.); (I.A.N.N.)
- Faculty of Pharmaceutical Sciences, Federal University of Amazonas—UFAM, Manaus 69080-900, AM, Brazil
| | - Stephanie Dias Soares
- Laboratory of Bioflavours and Bioactive Compounds, Department of Food Science, Faculty of Food Engineering, University of Campinas, Campinas 13083-862, SP, Brazil; (S.D.S.); (W.Q.d.O.); (A.d.S.L.); (I.A.N.N.)
| | - Williara Queiroz de Oliveira
- Laboratory of Bioflavours and Bioactive Compounds, Department of Food Science, Faculty of Food Engineering, University of Campinas, Campinas 13083-862, SP, Brazil; (S.D.S.); (W.Q.d.O.); (A.d.S.L.); (I.A.N.N.)
| | - Adriana de Souza Lima
- Laboratory of Bioflavours and Bioactive Compounds, Department of Food Science, Faculty of Food Engineering, University of Campinas, Campinas 13083-862, SP, Brazil; (S.D.S.); (W.Q.d.O.); (A.d.S.L.); (I.A.N.N.)
- Faculty of Tourism and Hospitality, Federal Fluminense University—UFF, Gragoatá Campus, Niterói 24210-200, RJ, Brazil
| | - Iramaia Angélica Neri Numa
- Laboratory of Bioflavours and Bioactive Compounds, Department of Food Science, Faculty of Food Engineering, University of Campinas, Campinas 13083-862, SP, Brazil; (S.D.S.); (W.Q.d.O.); (A.d.S.L.); (I.A.N.N.)
| | - Gláucia Maria Pastore
- Laboratory of Bioflavours and Bioactive Compounds, Department of Food Science, Faculty of Food Engineering, University of Campinas, Campinas 13083-862, SP, Brazil; (S.D.S.); (W.Q.d.O.); (A.d.S.L.); (I.A.N.N.)
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de Man A, Long MT, Stoppe C. Vitamin C for all? Curr Opin Crit Care 2024; 30:298-304. [PMID: 38841995 DOI: 10.1097/mcc.0000000000001161] [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: 06/07/2024]
Abstract
PURPOSE OF REVIEW Vitamin C can be a potential adjunctive treatment option for critically ill individuals due to its pleiotropic effects as electron donor in many enzymatic reactions throughout the body. Recently, several important randomized controlled trials (RCTs) investigating vitamin C in critically ill patients have been published. RECENT FINDINGS Two recent large RCTs administering high-dose vitamin C to patients with sepsis and COVID-19 showed signs of harm. Though performed at high standard, these trials had several limitations. Recent studies in cardiac surgery and burns showed decreased cardiac enzymes and improved clinical outcomes after cardiac surgery, and decreased fluid requirements, reduced wound healing time and in-hospital mortality after burns. Vitamin C may hold benefit in the management of other ischemia/reperfusion injury populations, including postcardiac arrest patients and after solid organ transplantation. Currently, covering basal vitamin C requirements during critical illness is recommended, though the exact dose remains to be determined. SUMMARY Future work should address optimal vitamin C timing, since early versus late drug administration are likely distinct, and duration of therapy, where withdrawal-induced injury is possible. Additionally accurate assessment of body stores with determination of individual vitamin requirements is crucial to ascertain patient and subgroups most likely to benefit from vitamin C.
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Affiliation(s)
- Angelique de Man
- Amsterdam UMC, location Vrije Universiteit, Department of Intensive Care, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, The Netherland
| | - Micah T Long
- Departments of Anesthesiology, Internal Medicine & Emergency Medicine, University of Wisconsin Hospitals & Clinics, Madison, Wisconsin, USA
| | - Christian Stoppe
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, Wuerzburg, Germany
- German Heart Center Charité Berlin, Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany
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Deng J, Zuo QK, Venugopal K, Hung J, Zubair A, Blais S, Porter V, Moskalyk M, Heybati K. Efficacy and Safety of Hydrocortisone, Ascorbic Acid, and Thiamine Combination Therapy for the Management of Sepsis and Septic Shock: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Int Arch Allergy Immunol 2024; 185:997-1018. [PMID: 38870923 PMCID: PMC11446305 DOI: 10.1159/000538959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/14/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION This systematic review aimed to assess the efficacy and safety of hydrocortisone, ascorbic acid, and thiamine (HAT) combination therapy in patients with sepsis and septic shock. METHODS We conducted a database search in MEDLINE, Embase, CENTRAL, Web of Science, and CNKI for randomised controlled trials (RCTs) comparing HAT against placebo/standard of care or against hydrocortisone in sepsis/septic shock patients. Outcomes included mortality, ICU/hospital length of stay (LOS), vasopressor durations, mechanical ventilation durations, change in SOFA at 72 h, and adverse events. RCT results were pooled in random-effects meta-analyses. Quality of evidence was assessed using GRADE. RESULTS Fifteen RCTs (N = 2,594) were included. At 72 h, HAT reduced SOFA scores from baseline (mean difference [MD] -1.16, 95% confidence interval [CI]: -1.58 to -0.74, I2 = 0%) compared to placebo/SoC, based on moderate quality of evidence. HAT also reduced the duration of vasopressor use (MD -18.80 h, 95% CI: -23.67 to -13.93, I2 = 64%) compared to placebo/SoC, based on moderate quality of evidence. HAT increased hospital LOS (MD 2.05 days, 95% CI: 0.15-3.95, I2 = 57%) compared to placebo/SoC, based on very low quality of evidence. HAT did not increase incidence of adverse events compared to placebo/SoC. CONCLUSIONS HAT appears beneficial in reducing vasopressor use and improving organ function in sepsis/septic shock patients. However, its advantages over hydrocortisone alone remain unclear. Future research should use hydrocortisone comparators and distinguish between sepsis-specific and comorbidity- or care-withdrawal-related mortality.
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Affiliation(s)
- Jiawen Deng
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Qi Kang Zuo
- UBC Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kaden Venugopal
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Jay Hung
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Areeba Zubair
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sara Blais
- UBC Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Victoria Porter
- UBC Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Myron Moskalyk
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Kiyan Heybati
- Mayo Clinic Alix School of Medicine (Jacksonville), Mayo Clinic, Jacksonville, Florida, USA
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Mumin MA, McKenzie CA, Page VJ, Hadfield D, Aitken LM, Hanks F, Cunningham E, Blackwood B, Van Dellen E, Slooter AJC, Grocott MPW, McAuley DF, Spronk PE. Whole blood thiamine, intravenous thiamine supplementation and delirium occurrence in the intensive care unit: retrospective cohort analyses. Int J Clin Pharm 2024; 46:631-638. [PMID: 38332207 DOI: 10.1007/s11096-023-01690-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/11/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND Thiamine di-phosphate is an essential cofactor in glucose metabolism, glutamate transformation and acetylcholinesterase activity, pathways associated with delirium occurrence. We hypothesised that a deficiency in whole blood thiamine and intravenous thiamine supplementation could impact delirium occurrence. AIM To establish whether a deficiency in whole blood thiamine and/or intravenous thiamine supplementation within 72 h of intensive care admission is associated with delirium occurrence. METHOD The first dataset was secondary analysis of a previous study in an intensive care unit in the Netherlands, reported in 2017. The second dataset contained consecutive intensive care admissions 2 years before (period 1: October 2014 to October 2016) and after (period 2: April 2017 to April 2019) routine thiamine supplementation was introduced within 72 h of admission. Delirium was defined as a positive Confusion Assessment Method-Intensive Care Unit score(s) in 24 h. RESULTS Analysis of the first dataset (n = 57) using logistic regression showed no relationship between delirium and sepsis or whole blood thiamine, but a significant association with age (p = 0.014). In the second dataset (n = 3074), 15.1% received IV thiamine in period 1 and 62.6% during period 2. Hierarchical regression analysis reported reduction in delirium occurrence in the second period; this did not reach statistical significance, OR = 0.81 (95% CI 0.652-1.002); p = 0.052. CONCLUSION No relationship was detected between whole blood thiamine and delirium occurrence on admission, at 24 and 48 h. It remains unclear whether routine intravenous thiamine supplementation during intensive care admission impacts delirium occurrence. Further prospective randomised clinical trials are needed.
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Affiliation(s)
- Muhammad A Mumin
- King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
- Institute of Pharmaceutical Sciences, Kings College London, London, UK.
- National Institute of Health and Social Care Research, Biomedical Research Centre, Perioperative and Critical Care Theme, University of Southampton School of Medicine, Southampton, UK.
| | - Cathrine A McKenzie
- Institute of Pharmaceutical Sciences, Kings College London, London, UK
- National Institute of Health and Social Care Research, Biomedical Research Centre, Perioperative and Critical Care Theme, University of Southampton School of Medicine, Southampton, UK
- Pharmacy and Critical Care, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Valerie J Page
- Intensive Care, West Hertfordshire NHS Foundation Trust, Watford General Hospital, Vicarage Road, Watford, Hertfordshire, UK
| | - Daniel Hadfield
- Institute of Pharmaceutical Sciences, Kings College London, London, UK
- King's Critical Care, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Leanne M Aitken
- School of Health and Psychological Sciences, City, University of London, Northampton Square, London, UK
| | - Fraser Hanks
- Institute of Pharmaceutical Sciences, Kings College London, London, UK
- Pharmacy, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Emma Cunningham
- Centre for Public Health, Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Bronagh Blackwood
- Centre for Public Health, Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Edwin Van Dellen
- Departments of Psychiatry and Intensive Care, UMC Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Neurology, UZ Brussel and Vrrije Universiteit Brussel, Brussels, Belgium
| | - Arjen J C Slooter
- Departments of Psychiatry and Intensive Care, UMC Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Neurology, UZ Brussel and Vrrije Universiteit Brussel, Brussels, Belgium
| | - Michael P W Grocott
- National Institute of Health and Social Care Research, Biomedical Research Centre, Perioperative and Critical Care Theme, University of Southampton School of Medicine, Southampton, UK
- Pharmacy and Critical Care, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Daniel F McAuley
- Centre for Public Health, Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Peter E Spronk
- Department of Intensive Care Medicine, Gelre Ziekenhuizen Apeldoorn, Apeldoorn, The Netherlands
- Expertise Center for Intensive Care Rehabilitation (ExpIRA), Apeldoorn, The Netherlands
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Berg KM, Grossestreuer AV, Balaji L, Moskowitz A, Berlin N, Cocchi MN, Morton AC, Li F, Mehta S, Peradze N, Silverman J, Liu X, Donnino MW. Thiamine as a metabolic resuscitator after in-hospital cardiac arrest. Resuscitation 2024; 198:110160. [PMID: 38428722 DOI: 10.1016/j.resuscitation.2024.110160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/13/2024] [Accepted: 02/23/2024] [Indexed: 03/03/2024]
Abstract
INTRODUCTION Elevated lactate is associated with mortality after cardiac arrest. Thiamine, a cofactor of pyruvate dehydrogenase, is necessary for aerobic metabolism. In a mouse model of cardiac arrest, thiamine improved pyruvate dehydrogenase activity, survival and neurologic outcome. AIM To determine if thiamine would decrease lactate and increase oxygen consumption after in-hospital cardiac arrest. METHODS Randomized, double-blind, placebo-controlled phase II trial. Adult patients with arrest within 12 hours, mechanically ventilated, with lactate ≥ 3 mmol/L were included. Randomization was stratified by lactate > 5 or ≤ 5 mmol/L. Thiamine 500 mg or placebo was administered every 12 hours for 3 days. The primary outcome of lactate was checked at baseline, 6, 12, 24, and 48 hours, and compared using a linear mixed model, accounting for repeated measures. Secondary outcomes included oxygen consumption, pyruvate dehydrogenase, and mortality. RESULTS Enrollments stopped after 36 patients due Data Safety and Monitoring Board concern about potential harm in an unplanned subgroup analysis. There was no overall difference in lactate (mean difference at 48 hours 1.5 mmol/L [95% CI -3.1-6.1], global p = 0.88) or any secondary outcomes. In those with randomization lactate > 5 mmol/L, mortality was 92% (11/12) with thiamine and 67% (8/12) with placebo (p = 0.32). In those with randomization lactate ≤ 5 mmol/L mortality was 17% (1/6) with thiamine and 67% (4/6) with placebo (p = 0.24). There was a significant interaction between randomization lactate and the effect of thiamine on survival (p = 0.03). CONCLUSIONS In this single center trial thiamine had no overall effect on lactate after in-hospital cardiac arrest.
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Affiliation(s)
- Katherine M Berg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA.
| | - Anne V Grossestreuer
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Lakshman Balaji
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Ari Moskowitz
- Division of Critical Care Medicine, Montefiore Medical Center, the Bronx, NY, USA; Bronx Center for Critical Care Outcomes and Resuscitation Research, the Bronx, NY, USA
| | - Noa Berlin
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA, USA
| | - Michael N Cocchi
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Andrea C Morton
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Franklin Li
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Shivani Mehta
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; New York Institute of Technology College of Osteopathic Medicine, 101 Northern Boulevard, Glen Head, NY 11545, USA
| | - Natia Peradze
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Jeremy Silverman
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Xiaowen Liu
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
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9
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Lazar A. Recent Data about the Use of Corticosteroids in Sepsis-Review of Recent Literature. Biomedicines 2024; 12:984. [PMID: 38790946 PMCID: PMC11118609 DOI: 10.3390/biomedicines12050984] [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: 03/28/2024] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 05/26/2024] Open
Abstract
Sepsis, characterized by life-threatening organ dysfunction due to a maladaptive host response to infection, and its more severe form, septic shock, pose significant global health challenges. The incidence of these conditions is increasing, highlighting the need for effective treatment strategies. This review explores the complex pathophysiology of sepsis, emphasizing the role of the endothelium and the therapeutic potential of corticosteroids. The endothelial glycocalyx, critical in maintaining vascular integrity, is compromised in sepsis, leading to increased vascular permeability and organ dysfunction. Corticosteroids have been used for over fifty years to treat severe infections, despite ongoing debate about their efficacy. Their immunosuppressive effects and the risk of exacerbating infections are significant concerns. The rationale for corticosteroid use in sepsis is based on their ability to modulate the immune response, promote cardiovascular stability, and potentially facilitate organ restoration. However, the evidence is mixed, with some studies suggesting benefits in terms of microcirculation and shock reversal, while others report no significant impact on mortality or organ dysfunction. The Surviving Sepsis Campaign provides cautious recommendations for their use. Emerging research highlights the importance of genomic and transcriptomic analyses in identifying patient subgroups that may benefit from corticosteroid therapy, suggesting a move toward personalized medicine in sepsis management. Despite potential benefits, the use of corticosteroids in sepsis requires careful consideration of individual patient risk profiles, and further research is needed to optimize their use and integrate genomic insights into clinical practice. This review underscores the complexity of sepsis treatment and the ongoing need for evidence-based approaches to improve patient outcomes.
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Affiliation(s)
- Alexandra Lazar
- Anesthesiology and Intensive Care Department, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology from Tirgu Mures, 540142 Targu Mures, Romania
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10
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Pei H, Qu J, Chen JM, Zhang YL, Zhang M, Zhao GJ, Lu ZQ. The effects of antioxidant supplementation on short-term mortality in sepsis patients. Heliyon 2024; 10:e29156. [PMID: 38644822 PMCID: PMC11033118 DOI: 10.1016/j.heliyon.2024.e29156] [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: 07/14/2023] [Revised: 03/28/2024] [Accepted: 04/02/2024] [Indexed: 04/23/2024] Open
Abstract
Background The occurrence and development of sepsis are related to the excessive production of oxygen free radicals and the weakened natural clearance mechanism. Further dependable evidence is required to clarify the effectiveness of antioxidant therapy, especially its impact on short-term mortality. Objectives The purpose of this systematic review and meta-analysis was to evaluate the effect of common antioxidant therapy on short-term mortality in patients with sepsis. Methods According to PRISMA guidelines, a systematic literature search on antioxidants in adults sepsis patients was performed on PubMed/Medline, Embase, and the Cochrane Library from the establishment of the database to November 2023. Antioxidant supplements can be a single-drug or multi-drug combination: HAT (hydrocortisone, ascorbic acid, and thiamine), ascorbic acid, thiamine, N-acetylcysteine and selenium. The primary outcome was the effect of antioxidant treatment on short-term mortality, which included 28-day mortality, in-hospital mortality, intensive care unit mortality, and 30-day mortality. Subgroup analyses of short-term mortality were used to reduce statistical heterogeneity and publication bias. Results Sixty studies of 130,986 sepsis patients fulfilled the predefined criteria and were quantified and meta-analyzed. Antioxidant therapy reduces the risk of short-term death in sepsis patients by multivariate meta-analysis of current data, including a reduction of in-hospital mortality (OR = 0.81, 95% CI 0.67 to 0.99; P = 0.040) and 28-day mortality (OR = 0.81, 95% CI 0.69 to 0.95]; P = 0.008). Particularly in subgroup analyses, ascorbic acid treatment can reduce in-hospital mortality (OR = 0.66, 95% CI 0.90 to 0.98; P = 0.006) and 28-day mortality (OR = 0.43, 95% CI 0.24 to 0.75; P = 0.003). However, the meta-analysis of RCTs found that antioxidant therapy drugs, especially ascorbic acid, did substantially reduce short-term mortality(OR = 0.78, 95% CI 0.62 to 0.98; P = 0.030; OR = 0.57, 95% CI 0.36 to 0.91; P = 0.020). Conclusions According to current data of RCTs, antioxidant therapy, especially ascorbic acid, has a trend of improving short-term mortality in patients with sepsis, but the evidence remains to be further demonstrated.
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Affiliation(s)
- Hui Pei
- Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Jie Qu
- Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Jian-Ming Chen
- Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Yao-Lu Zhang
- Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Min Zhang
- Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Guang-Ju Zhao
- Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Emergency and Disaster Medicine, Wenzhou, 325000, China
| | - Zhong-Qiu Lu
- Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Emergency and Disaster Medicine, Wenzhou, 325000, China
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11
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Gonzalez Londoño J, Vera Ching C, Sebastian Cernuda P, Morales Pedrosa JM, Lorencio C, Sirvent JM. Effect of vitamin C, thiamine and hydrocortisone in critically ill septic patients. The Metabolic Resus RCT. Med Intensiva 2024; 48:238-240. [PMID: 37985341 DOI: 10.1016/j.medine.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/28/2023] [Accepted: 10/08/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Juliana Gonzalez Londoño
- Critical Care Department, Hospital Santa Caterina, Salt, Girona, Spain; Institut d'Investigació Biomédica de Girona Dr. Josep Trueta, Girona, Spain.
| | - Claudia Vera Ching
- Critical Care Department, Hospital Universitario de Girona Doctor Josep Trueta, Girona, Spain
| | | | - Josep Miquel Morales Pedrosa
- Critical Care Department, Hospital Santa Caterina, Salt, Girona, Spain; Institut d'Investigació Biomédica de Girona Dr. Josep Trueta, Girona, Spain
| | - Carol Lorencio
- Institut d'Investigació Biomédica de Girona Dr. Josep Trueta, Girona, Spain; Critical Care Department, Hospital Universitario de Girona Doctor Josep Trueta, Girona, Spain
| | - Josep-Maria Sirvent
- Critical Care Department, Hospital Santa Caterina, Salt, Girona, Spain; Institut d'Investigació Biomédica de Girona Dr. Josep Trueta, Girona, Spain; Critical Care Department, Hospital Universitario de Girona Doctor Josep Trueta, Girona, Spain
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12
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Ge Z, Gao Y, Lu X, Yu S, Qin M, Gong C, Walline JH, Zhu H, Li Y. The association between levosimendan and mortality in patients with sepsis or septic shock: a systematic review and meta-analysis. Eur J Emerg Med 2024; 31:90-97. [PMID: 38015719 PMCID: PMC10901220 DOI: 10.1097/mej.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/21/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Levosimendan is increasingly being used in patients with sepsis or septic shock because of its potential to improve organ function and reduce mortality. We aimed to determine if levosimendan can reduce mortality in patients with sepsis or septic shock via meta-analysis. EVIDENCE SOURCES AND STUDY SELECTION We comprehensively searched the PubMed, Embase, Web of Science, and Cochrane Library databases from inception through 1 October 2022. Literature evaluating the efficacy of levosimendan in patients with sepsis or septic shock was included. DATA EXTRACTION AND OUTCOME MEASUREMENTS Two reviewers extracted data and assessed study quality. A meta-analysis was performed to calculate an odds ratio (OR), 95% confidence intervals (CI), and P -values for 28-day mortality (primary outcome). Secondary outcomes included changes in indexes reflecting cardiac function before and after treatment, changes in serum lactate levels in the first 24 h of treatment, and the mean SOFA score during the study period. Safety outcomes included rates of tachyarrhythmias and total adverse reactions encountered with levosimendan. RESULTS Eleven randomized controlled trials were identified, encompassing a total of 1044 patients. After using levosimendan, there was no statistical difference between groups for 28-day mortality (34.9% and 36.2%; OR: 0.93; 95% CI [0.72-1.2]; P = 0.57; I 2 = 0%; trial sequential analysis-adjusted CI [0.6-1.42]) and sequential organ failure assessment (SOFA) score, and more adverse reactions seemed to occur in the levosimendan group, although the septic shock patient's heart function and serum lactate level improved. CONCLUSION There was no association between the use of levosimendan and 28-day mortality and SOFA scores in patients with septic shock, though there was statistically significant improvement in cardiac function and serum lactate.
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Affiliation(s)
- Zengzheng Ge
- Emergency Department, State Key Laboratory for Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing
| | - Yanxia Gao
- Department of Emergency Medicine, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Lu
- Emergency Department, State Key Laboratory for Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing
| | - Shiyuan Yu
- Emergency Department, State Key Laboratory for Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing
| | - Mubing Qin
- Emergency Department, State Key Laboratory for Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing
| | - Chao Gong
- Emergency Department, State Key Laboratory for Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing
| | - Joseph Harold Walline
- Department of Emergency Medicine, Penn State Health, Milton S. Hershey Medical Center and Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Huadong Zhu
- Emergency Department, State Key Laboratory for Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing
| | - Yi Li
- Emergency Department, State Key Laboratory for Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing
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13
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Yong S, Suping L, Peng Z, Dong L, Qing W. The effects of vitamin C supplementation in the critically ill patients outcomes: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2024; 103:e37420. [PMID: 38518058 PMCID: PMC10956978 DOI: 10.1097/md.0000000000037420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/07/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND Vitamin C has significant anti-inflammatory effects and is particularly important for critically ill patients. However due to inconsistent research findings in critically ill patients in meta-analysis. Therefore, the primary objective of this meta-analysis is to investigate the effects of isolated intravenous supplementation of vitamin C in adults with critical illness by comprehensively incorporating articles from randomized controlled trials. METHODS Articles included searching through PubMed, Embase, Medline, Cochrane Library, and Web of Science up to April 28, 2023, for articles on vitamin C and the critically ill. We calculated pooled standard relative risk (RR), mean difference (MD), and 95% confidence intervals (CIs). And the protocol for the review has been registered on PROSPERO (CRD42023425193). RESULTS There are 2047 critically ill included in 19 articles. Compared with placebo, patients who underwent intravenous vitamin C (IVVC) have reduced duration of vasopressor used (SMD 0.26; CI 0.01-0.51; I2 = 87.0%, P = .044), mechanical ventilation (SMD -0.29; CI -0.55 to -0.03; I2 = 36.8%, P = .031). However, the administration of IVVC had no statistical difference in 28-d mortality (RR 0.95; CI 0.80-1.11; I2 = 12.2%, P = .337), mortality (RR 0.79; CI 0.55-1.12; I2 = 0%, P = .188), fluid intake (SMD -0.02; CI -0.25 to 0.20; I2 = 0%, P = .838), urine output (SMD 0.23; CI -0.03 to 0.49; I2 = 0%, P = .084), ICU days (SMD 0.10; CI -0.03 to 0.22; I2 = 0%, P = .127), hospital stay (SMD 0.10; CI -0.12 to 0.32; I2 = 0%, P = .375), and pneumonia (RR 0.85; CI 0.50-1.44; I2 = 0%, P = .552). CONCLUSION This study comprehensively and systematically evaluated IVVC supplementation in the critically ill through a meta-analysis of RCT. There is no difference except for patients who had reduced duration of vasopressor use and mechanical ventilation by the administration of IVVC. Of course. More scientific and rigorous conclusions can be drawn from multi-center RCT research in the future.
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Affiliation(s)
- Su Yong
- Intensive Care Unit, Pengzhou People’s Hospital, Pengzhou City, Chengdu, Sichuan, China
| | - Liu Suping
- Intensive Care Unit, Pengzhou People’s Hospital, Pengzhou City, Chengdu, Sichuan, China
| | - Zhang Peng
- Department of Gastrointestinal Surgery, Pengzhou People’s Hospital, Pengzhou City, Chengdu, Sichuan, China
| | - Lin Dong
- Department of Urology, Pengzhou People’s Hospital, Pengzhou City, Chengdu, Sichuan, China
| | - Wei Qing
- Intensive Care Unit, Pengzhou People’s Hospital, Pengzhou City, Chengdu, Sichuan, China
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14
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Slim MA, Turgman O, van Vught LA, van der Poll T, Wiersinga WJ. Non-conventional immunomodulation in the management of sepsis. Eur J Intern Med 2024; 121:9-16. [PMID: 37919123 DOI: 10.1016/j.ejim.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023]
Abstract
Sepsis remains a critical global health issue, demanding novel therapeutic strategies. Traditional immunomodulation treatments such as corticosteroids, specific modifiers of cytokines, complement or coagulation, growth factors or immunoglobulins, have so far fallen short. Meanwhile the number of studies investigating non-conventional immunomodulatory strategies is expanding. This review provides an overview of adjunctive treatments with herbal-based medicine, immunonutrition, vasopressors, sedative treatments and targeted temperature management, used to modulate the immune response in patients with sepsis. Herbal-based medicine, notably within traditional Chinese medicine, shows promise. Xuebijing injection and Shenfu injection exhibit anti-inflammatory and immune-modulatory effects, and the potential to lower 28-day mortality in sepsis. Selenium supplementation has been reported to reduce the occurrence of ventilator-associated pneumonia among sepsis patients, but study results are conflicting. Likewise, the immune-suppressive effects of omega-3 fatty acids have been associated with improved clinical outcomes in sepsis. The immunomodulating properties of supportive treatments also gain interest. Vasopressors like norepinephrine exhibit dual dosage-dependent roles, potentially promoting both pro- and anti-inflammatory effects. Dexmedetomidine, a sedative, demonstrates anti-inflammatory properties, reducing sepsis mortality rates in some studies. Temperature management, particularly maintaining higher body temperature, has also been associated with improved outcomes in small scale human trials. In conclusion, emerging non-conventional immunomodulatory approaches, including herbal medicine, immunonutrition, and targeted supportive therapies, hold potential for sepsis treatment, but their possible implementation into everyday clinical practice necessitates further research and stringent clinical validation in different settings.
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Affiliation(s)
- M A Slim
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Intensive Care, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands.
| | - O Turgman
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - L A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Intensive Care, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - T van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - W J Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
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15
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Hu J, Zhang J, Li D, Hu X, Li Q, Wang W, Su J, Wu D, Kang H, Zhou F. Predicting hypovitaminosis C with LASSO algorithm in adult critically ill patients in surgical intensive care units: a bi-center prospective cohort study. Sci Rep 2024; 14:5073. [PMID: 38429378 PMCID: PMC10907613 DOI: 10.1038/s41598-024-54826-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/16/2024] [Indexed: 03/03/2024] Open
Abstract
Vitamin C played pleiotropic roles in critical illness and vitamin C insufficiency was predictive of the development of multiple organ failure. Currently, the prevalence of vitamin C insufficiency in Chinese critically ill patients is rarely determined and there are no established bedside tools to predict hypovitaminosis C. To develop a nomogram to identify patients with high risk of hypovitaminosis C, we performed a bi-center prospective cohort study at two ICUs of the first and sixth medical center in PLA General Hospital, Beijing, China from May 6th to July 31st, 2021 We identified 322 eligible patients. 62.4% patients were hypovitaminosis C. 7 features, including source of infection, the level of serum albumin, age, male gender, sepsis, vascular disease, and wasting of vitamin C by the kidney, were selected using LASSO algorithm and therefore included in the nomogram. In the testing set, our model showed moderate discrimination ability with areas under the curve of 0.75 [0.64-0.84]. Variable importance evaluated by SHAP value highlighted two novel important predictors, i.e., abdominal infection and the level of serum albumin. In conclusion, we first reported a high burden of vitamin C insufficiency in Chinese adult patient in the ICU. We also constructed a prediction model to timely identify patients with high risk of hypovitaminosis C, which allows the clinicians to choose appropriate candidates for Vitamin C repletion in clinical practice or clinical trials.
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Affiliation(s)
- Jie Hu
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
- National Key Laboratory of Kidney Diseases, Beijing, 100853, People's Republic of China
| | - Jingwen Zhang
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Dawei Li
- Department of Critical Care Medicine, The Sixth Medical Centre, Chinese PLA General Hospital, Beijing, 100048, People's Republic of China
| | - Xin Hu
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Qi Li
- Department of Critical Care Medicine, The Sixth Medical Centre, Chinese PLA General Hospital, Beijing, 100048, People's Republic of China
| | - Wenwen Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Cheeloo Medical College, Shandong University, Jinan, 250013, People's Republic of China
| | - Jianguo Su
- Department of Critical Care Medicine, NingXia Chinese Medicine Research Center, Yinchuan, 750021, People's Republic of China
| | - Di Wu
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, People's Republic of China
| | - Hongjun Kang
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Feihu Zhou
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China.
- Medical Engineering Laboratory of Chinese, PLA General Hospital, Beijing, 100853, People's Republic of China.
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16
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Montero-Jodra A, de la Fuente MÁ, Gobelli D, Martín-Fernández M, Villar J, Tamayo E, Simarro M. The mitochondrial signature of cultured endothelial cells in sepsis: Identifying potential targets for treatment. Biochim Biophys Acta Mol Basis Dis 2024; 1870:166946. [PMID: 37939908 DOI: 10.1016/j.bbadis.2023.166946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023]
Abstract
Sepsis is the most common cause of death from infection in the world. Unfortunately, there is no specific treatment for patients with sepsis, and management relies on infection control and support of organ function. A better understanding of the underlying pathophysiology of this syndrome will help to develop innovative therapies. In this regard, it has been widely reported that endothelial cell activation and dysfunction are major contributors to the development of sepsis. This review aims to provide a comprehensive overview of emerging findings highlighting the prominent role of mitochondria in the endothelial response in in vitro experimental models of sepsis. Additionally, we discuss potential mitochondrial targets that have demonstrated protective effects in preclinical investigations against sepsis. These promising findings hold the potential to pave the way for future clinical trials in the field.
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Affiliation(s)
- Alba Montero-Jodra
- Department of Surgery, University of Valladolid, Valladolid, Spain; Unit of Excellence, Institute of Biomedicine and Molecular Genetics (IBGM), University of Valladolid and Spanish National Research Council (CSIC), Valladolid, Spain
| | - Miguel Ángel de la Fuente
- Unit of Excellence, Institute of Biomedicine and Molecular Genetics (IBGM), University of Valladolid and Spanish National Research Council (CSIC), Valladolid, Spain; Department of Cell Biology, Genetics, Histology and Pharmacology, University of Valladolid, Valladolid, Spain
| | - Dino Gobelli
- Unit of Excellence, Institute of Biomedicine and Molecular Genetics (IBGM), University of Valladolid and Spanish National Research Council (CSIC), Valladolid, Spain; Department of Cell Biology, Genetics, Histology and Pharmacology, University of Valladolid, Valladolid, Spain
| | - Marta Martín-Fernández
- Department of Cell Biology, Genetics, Histology and Pharmacology, University of Valladolid, Valladolid, Spain; BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Research Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain; Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario, Canada
| | - Eduardo Tamayo
- Department of Surgery, University of Valladolid, Valladolid, Spain; BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Department of Anaesthesiology & Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - María Simarro
- Unit of Excellence, Institute of Biomedicine and Molecular Genetics (IBGM), University of Valladolid and Spanish National Research Council (CSIC), Valladolid, Spain; Department of Cell Biology, Genetics, Histology and Pharmacology, University of Valladolid, Valladolid, Spain
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17
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Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics 2024; 153:e2023062967. [PMID: 38084084 PMCID: PMC11058732 DOI: 10.1542/peds.2023-062967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 01/02/2024] Open
Abstract
Sepsis and septic shock are major causes of morbidity, mortality, and health care costs for children worldwide, including >3 million deaths annually and, among survivors, risk for new or worsening functional impairments, including reduced quality of life, new respiratory, nutritional, or technological assistance, and recurrent severe infections. Advances in understanding sepsis pathophysiology highlight a need to update the definition and diagnostic criteria for pediatric sepsis and septic shock, whereas new data support an increasing role for automated screening algorithms and biomarker combinations to assist earlier recognition. Once sepsis or septic shock is suspected, attention to prompt initiation of broad-spectrum empiric antimicrobial therapy, fluid resuscitation, and vasoactive medications remain key components to initial management with several new and ongoing studies offering new insights into how to optimize this approach. Ultimately, a key goal is for screening to encompass as many children as possible at risk for sepsis and trigger early treatment without increasing unnecessary broad-spectrum antibiotics and preventable hospitalizations. Although the role for adjunctive treatment with corticosteroids and other metabolic therapies remains incompletely defined, ongoing studies will soon offer updated guidance for optimal use. Finally, we are increasingly moving toward an era in which precision therapeutics will bring novel strategies to improve outcomes, especially for the subset of children with sepsis-induced multiple organ dysfunction syndrome and sepsis subphenotypes for whom antibiotics, fluid, vasoactive medications, and supportive care remain insufficient.
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Affiliation(s)
- Scott L. Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children’s Health, Wilmington, DE, USA
- Departments of Pediatrics & Pathology, Anatomy, and Cell Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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18
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Pitre T, Drover K, Chaudhuri D, Zeraaktkar D, Menon K, Gershengorn HB, Jayaprakash N, Spencer-Segal JL, Pastores SM, Nei AM, Annane D, Rochwerg B. Corticosteroids in Sepsis and Septic Shock: A Systematic Review, Pairwise, and Dose-Response Meta-Analysis. Crit Care Explor 2024; 6:e1000. [PMID: 38250247 PMCID: PMC10798738 DOI: 10.1097/cce.0000000000001000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024] Open
Abstract
OBJECTIVES To perform a systematic review and meta-analysis to assess the efficacy and safety of corticosteroids in patients with sepsis. DATA SOURCES We searched PubMed, Embase, and the Cochrane Library, up to January 10, 2023. STUDY SELECTION We included randomized controlled trials (RCTs) comparing corticosteroids with placebo or standard care with sepsis. DATA EXTRACTION The critical outcomes of interest included mortality, shock reversal, length of stay in the ICU, and adverse events. DATA ANALYSIS We performed both a pairwise and dose-response meta-analysis to evaluate the effect of different corticosteroid doses on outcomes. We used Grading of Recommendations Assessment, Development and Evaluation to assess certainty in pooled estimates. DATA SYNTHESIS We included 45 RCTs involving 9563 patients. Corticosteroids probably reduce short-term mortality (risk ratio [RR], 0.93; 95% CI, 0.88-0.99; moderate certainty) and increase shock reversal at 7 days (RR, 1.24; 95% CI, 1.11-1.38; high certainty). Corticosteroids may have no important effect on duration of ICU stay (mean difference, -0.6 fewer days; 95% CI, 1.48 fewer to 0.27 more; low certainty); however, probably increase the risk of hyperglycemia (RR, 1.13; 95% CI, 1.08-1.18; moderate certainty) and hypernatremia (RR, 1.64; 95% CI, 1.32-2.03; moderate certainty) and may increase the risk of neuromuscular weakness (RR, 1.21; 95% CI, 1.01-1.45; low certainty). The dose-response analysis showed a reduction in mortality with corticosteroids with optimal dosing of approximately 260 mg/d of hydrocortisone (RR, 0.90; 95% CI, 0.83-0.98) or equivalent. CONCLUSIONS We found that corticosteroids may reduce mortality and increase shock reversal but they may also increase the risk of hyperglycemia, hypernatremia, and neuromuscular weakness. The dose-response analysis indicates optimal dosing is around 260 mg/d of hydrocortisone or equivalent.
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Affiliation(s)
- Tyler Pitre
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katherine Drover
- Department of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dipayan Chaudhuri
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Dena Zeraaktkar
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesiology, McMaster University, Hamilton, ON, Canada
| | - Kusum Menon
- Department of Pediatrics, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Namita Jayaprakash
- Department of Emergency Medicine and Division of Pulmonary and Critical Care Medicine, Henry Ford Health, Detroit, MI
| | - Joanna L Spencer-Segal
- Department of Internal Medicine and Michigan Neuroscience Institute, University of Michigan, Ann Arbor, MI
| | - Stephen M Pastores
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital-Rochester, Rochester, MN
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincare Hospital (APHP), Garches, France and the School of Medicine Simone Veil, University Paris Saclay-Campus UVSQ, Paris, France
| | - Bram Rochwerg
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, McMaster University, Hamilton, ON, Canada
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19
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Chudow MB, Condeni MS, Dhar S, Heavner MS, Nei AM, Bissell BD. Current Practice Review in the Management of Acute Respiratory Distress Syndrome. J Pharm Pract 2023; 36:1454-1471. [PMID: 35728076 DOI: 10.1177/08971900221108713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute respiratory distress syndrome (ARDS) presents as an acute inflammatory lung injury characterized by refractory hypoxemia and non-cardiac pulmonary edema. An estimated 10% of patients in the intensive care unit and 25% of those who are mechanically ventilated are diagnosed with ARDS. Increased awareness is warranted as mortality rates remain high and delays in diagnosing ARDS are common. The COVID-19 pandemic highlights the importance of understanding ARDS management. Treatment of ARDS can be challenging due to the complexity of the disease state and conflicting existing evidence. Therefore, it is imperative that pharmacists understand both pharmacologic and non-pharmacologic treatment strategies to optimize patient care. This narrative review provides a critical evaluation of current literature describing management practices for ARDS. A review of treatment modalities and supportive care strategies will be presented.
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Affiliation(s)
- Melissa B Chudow
- Department of Pharmacotherapeutics and Clinical Research, University of South Florida Taneja College of Pharmacy, Tampa, FL, USA
| | - Melanie S Condeni
- MUSC College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Sanjay Dhar
- Pulmonary Critical Care Ultrasound and Research, Pulmonary and Critical Care Fellowship Program, Division of Pulmonary, Critical Care & Sleep Medicine, University of Kentucky, Lexington, KY, USA
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Andrea M Nei
- Mayo Clinic College of Medicine & Science, Critical Care Pharmacist, Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN, USA
| | - Brittany D Bissell
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
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20
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Spannenburg L, Reed H. Adverse cognitive effects of glucocorticoids: A systematic review of the literature. Steroids 2023; 200:109314. [PMID: 37758053 DOI: 10.1016/j.steroids.2023.109314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 09/14/2023] [Accepted: 09/23/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES Glucocorticoids as a drug class are widely used in the treatment of many conditions including more recently as one of the mainstay treatments for the SARS-CoV-2 infection. The physiological adverse effects are well described. However, less is known and understood about the potentially deleterious neuro-cognitive effects of this class of medication. METHODS We carried out a systematic review of the literature using two separate search strategies. The first focussed on the rates of reporting of adverse cognitive effects of glucocorticoid use in randomised controlled trials. The second looked at those studies focussing directly on adverse cognitive effects associated with the use of glucocorticoids. MEDLINE, Embase and Cochrane Library was searched for randomised controlled trials utilising glucocorticoids as a part of a treatment regimen. Additionally, these databases were also used to search for articles looking directly at the adverse cognitive effects of glucocorticoids. RESULTS Of the forty-three RCTs included as a part of the first search strategy, only one (2.3%) included specific documentation pertaining to cognitive side effects. As a part of the twenty studies included in the second search strategy, eleven of the included studies (55%) were able to demonstrate a correlation between glucocorticoid use and decreased cognition. Most studies within this strategy showed that GCs predominately affected hippocampus-dependent functions such as memory, while sparing executive function and attention. CONCLUSIONS Overall, the data reporting of adverse clinical effects of glucocorticoid use is poor in recent RCTs. Given the demonstrable effect on predominately hippocampal-dependent cognitive functions evident within the literature, more thorough documentation is needed within clinical research to fully appreciate the potentially widespread nature of these effects.
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Affiliation(s)
- Liam Spannenburg
- Faculty of Medicine, University of Queensland, School of Clinical Medicine, Herston, QLD 4006, Australia; Metro South Hospital & Health Service, Department of Medicine, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia.
| | - Hayley Reed
- Faculty of Medicine, University of Queensland, School of Clinical Medicine, Herston, QLD 4006, Australia; Mater Research Institute, University of Queensland, Brisbane 4101, Australia
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21
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Wu J, Cai J, Tang Y, Lu B. The noncanonical inflammasome-induced pyroptosis and septic shock. Semin Immunol 2023; 70:101844. [PMID: 37778179 DOI: 10.1016/j.smim.2023.101844] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 09/10/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023]
Abstract
Sepsis remains one of the most common and lethal conditions globally. Currently, no proposed target specific to sepsis improves survival in clinical trials. Thus, an in-depth understanding of the pathogenesis of sepsis is needed to propel the discovery of effective treatment. Recently attention to sepsis has intensified because of a growing recognition of a non-canonical inflammasome-triggered lytic mode of cell death termed pyroptosis upon sensing cytosolic lipopolysaccharide (LPS). Although the consequences of activation of the canonical and non-canonical inflammasome are similar, the non-canonical inflammasome formation requires caspase-4/5/11, which enzymatically cleave the pore-forming protein gasdermin D (GSDMD) and thereby cause pyroptosis. The non-canonical inflammasome assembly triggers such inflammatory cell death by itself; or leverages a secondary activation of the canonical NLRP3 inflammasome pathway. Excessive cell death induced by oligomerization of GSDMD and NINJ1 leads to cytokine release and massive tissue damage, facilitating devastating consequences and death. This review summarized the updated mechanisms that initiate and regulate non-canonical inflammasome activation and pyroptosis and highlighted various endogenous or synthetic molecules as potential therapeutic targets for treating sepsis.
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Affiliation(s)
- Junru Wu
- Department of Cardiology, The 3rd Xiangya Hospital, Central South University, Changsha 410000, PR China
| | - Jingjing Cai
- Department of Cardiology, The 3rd Xiangya Hospital, Central South University, Changsha 410000, PR China
| | - Yiting Tang
- Department of Physiology, School of Basic Medical Science, Central South University, Changsha 410000, PR China
| | - Ben Lu
- Department of Critical Care Medicine and Hematology, The 3rd Xiangya Hospital, Central South University, Changsha 410000, PR China; Key Laboratory of Sepsis Translational Medicine of Hunan, Central South University, Changsha 410000, PR China.
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22
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Sun Y, Yang Y, Ye Z, Sun T. HAT therapy for sepsis: A review of the therapeutic rationale and current clinical evaluation status. JOURNAL OF INTENSIVE MEDICINE 2023; 3:320-325. [PMID: 38028642 PMCID: PMC10658041 DOI: 10.1016/j.jointm.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/03/2023] [Accepted: 04/20/2023] [Indexed: 12/01/2023]
Abstract
Vitamin C-based cluster therapy, which involves the combined application of hydrocortisone, vitamin C, and thiamine (HAT), is a recently proposed new treatment option for sepsis on top of conventional treatment. This therapy has a strong theoretical basis, but its clinical efficacy remains inconclusive. This review summarizes the rationale for HAT therapy for sepsis and describes the evaluation of its efficacy in clinical observational studies and randomized controlled trials, with the aim of providing a reference for the future clinical practice application of HAT therapy in sepsis.
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Affiliation(s)
- Yali Sun
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Zhengzhou 450052, Henan, China
- Henan Engineering Research Center for Critical Care Medicine, Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Yongfang Yang
- Henan Engineering Research Center for Critical Care Medicine, Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Zhuoyi Ye
- Henan Engineering Research Center for Critical Care Medicine, Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
| | - Tongwen Sun
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Zhengzhou 450052, Henan, China
- Henan Engineering Research Center for Critical Care Medicine, Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
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23
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Shapiro L, Scherger S, Franco-Paredes C, Gharamti A, Henao-Martinez AF. Anakinra authorized to treat severe coronavirus disease 2019; Sepsis breakthrough or time to reflect? Front Microbiol 2023; 14:1250483. [PMID: 37928695 PMCID: PMC10620707 DOI: 10.3389/fmicb.2023.1250483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/26/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction The European Medicines Agency (EMA) and the United States Food and Drug Administration (FDA) announced conditions for using recombinant human interleukin-1 receptor antagonist (rhIL-1ra) to treat hospitalized patients with Coronavirus disease 2019 (COVID-19) and risk for progression. These decisions followed publication of the suPAR-guided Anakinra treatment for Validation of the risk and early Management OF seveRE respiratory failure by COVID-19 (SAVE- MORE) phase 3 clinical trial that yielded positive results. Methods We conducted a literature review and theoretical analysis of IL-1 blockade as a therapy to treat COVID-19. Using a stepwise analysis, we assessed clinical applicability of the SAVE-MORE results and evaluated conceptual support for interleukin-1 suppression as a suitable approach to COVID-19 treatment. This therapeutic approach was then examined as an example of inflammation-suppressing measures used to treat sepsis. Results Anakinra use as a COVID-19 therapy seems to rely on a view of pathogenesis that incorrectly reflects human disease. Since COVID-19 is an example of sepsis, COVID-19 benefit due to anti-inflammatory therapy contradicts an extensive history of unsuccessful clinical study. Repurposing rhIL-1ra to treat COVID-19 appears to exemplify a cycle followed by inflammation-suppressing sepsis treatments. A landscape of treatment failures is interrupted by a successful clinical trial. However, subsequent confirmatory study fails to replicate the positive data. Discussion We suggest further experimentation is not a promising pathway to discover game-changing sepsis therapies. A different kind of approach may be necessary.
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Affiliation(s)
- Leland Shapiro
- Division of Infectious Diseases, Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Sias Scherger
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Carlos Franco-Paredes
- Hospital Infantil de México, Federico Gómez, México City, México
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Collins, CO, United States
| | - Amal Gharamti
- Department of Internal Medicine, Yale University, Waterbury, CT, United States
| | - Andrés F. Henao-Martinez
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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24
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Unar A, Bertolino L, Patauner F, Gallo R, Durante-Mangoni E. Decoding Sepsis-Induced Disseminated Intravascular Coagulation: A Comprehensive Review of Existing and Emerging Therapies. J Clin Med 2023; 12:6128. [PMID: 37834771 PMCID: PMC10573475 DOI: 10.3390/jcm12196128] [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: 07/31/2023] [Revised: 09/09/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is a recurrent complication of sepsis. Since DIC not only promotes organ dysfunction but also represents a strong prognostic factor, it is important to diagnose DIC as early as possible. When coagulation is activated, fibrinolysis is inhibited, blood thinners are consumed, and a condition is created that promotes blood clotting, making it more difficult for the body to remove fibrin or prevent it from being deposited in the blood vessels. This leads to microvascular thrombosis, which plays a role in organ dysfunction. Despite efforts to understand the underlying mechanisms of sepsis-induced DIC, healthcare providers worldwide still face challenges in effectively treating this condition. In this review, we provide an in-depth analysis of the available strategies for sepsis-induced DIC, considering their effectiveness, limitations, and potential for future advances. Corticosteroids (CS), recombinant thrombomodulin (rTM), vitamin C, fibrinolytic therapy, and platelet transfusion are among the treatments discussed in the review. In addition, we are specifically addressing immunomodulatory therapy (IMT) by investigating treatments such as granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon gamma (IFN-γ), and mesenchymal stem cell therapy (MSC). Finally, we also examined how these therapies might affect COVID-19 cases, which often present with sepsis-induced DIC. The review suggests that targeted experiments with randomization are needed to verify the effectiveness of these treatments and to discover novel approaches to treat sepsis-induced DIC. By increasing our knowledge of sepsis-induced DIC, we can develop targeted treatments that have the potential to save lives and improve outcomes.
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Affiliation(s)
- Ahsanullah Unar
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Lorenzo Bertolino
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Fabian Patauner
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Raffaella Gallo
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
- Unit of Infectious and Transplant Medicine, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy
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25
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Kamath S, Hammad Altaq H, Abdo T. Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades? Microorganisms 2023; 11:2231. [PMID: 37764075 PMCID: PMC10537306 DOI: 10.3390/microorganisms11092231] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.
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Affiliation(s)
| | | | - Tony Abdo
- Section of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center, The Oklahoma City VA Health Care System, Oklahoma City, OK 73104, USA; (S.K.); (H.H.A.)
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26
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Moskowitz A, Berg KM, Grossestreuer AV, Balaji L, Liu X, Cocchi MN, Chase M, Gong MN, Gong J, Parikh SM, Ngo L, Berlin N, Donnino MW. Thiamine for Renal Protection in Septic Shock (TRPSS): A Randomized, Placebo-controlled, Clinical Trial. Am J Respir Crit Care Med 2023; 208:570-578. [PMID: 37364280 PMCID: PMC10492240 DOI: 10.1164/rccm.202301-0034oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023] Open
Abstract
Rationale: Kidney injury is common and associated with worse outcomes in patients with septic shock. Mitochondrial resuscitation with thiamine (vitamin B1) may attenuate septic kidney injury. Objectives: To assess whether thiamine supplementation attenuates kidney injury in septic shock. Methods: The TRPSS (Thiamine for Renal Protection in Septic Shock) trial was a multicenter, randomized, placebo-controlled trial of thiamine versus placebo in septic shock. The primary outcome was change in serum creatinine between enrollment and 72 hours after enrollment. Measurements and Main Results: Eighty-eight patients were enrolled (42 patients received the intervention, and 46 received placebo). There was no significant between-groups difference in creatinine at 72 hours (mean difference, -0.57 mg/dl; 95% confidence interval, -1.18, 0.04; P = 0.07). There was no difference in receipt of kidney replacement therapy (14.3% vs. 21.7%, P = 0.34), acute kidney injury (as defined by stage 3 of the Kidney Disease: Improving Global Outcomes acute kidney injury scale; 54.7% vs. 73.9%, P = 0.07), or mortality (35.7% vs. 54.3%, P = 0.14) between the thiamine and placebo groups. Patients who received thiamine had more ICU-free days (median [interquartile range]: 22.5 [0.0-25.0] vs. 0.0 [0.0-23.0], P < 0.01). In the thiamine-deficient cohort (27.4% of patients), there was no difference in rates of kidney failure (57.1% thiamine vs. 81.5% placebo) or in-hospital mortality (28.6% vs. 68.8%) between groups. Conclusions: In the TRPSS trial, there was no statistically significant difference in the primary outcome of change in creatinine over time. Patients who received thiamine had more ICU-free days, but there was no difference in other secondary outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT03550794).
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Affiliation(s)
- Ari Moskowitz
- Division of Critical Care Medicine, Montefiore Medical Center, The Bronx, New York
- Bronx Center for Critical Care Outcomes and Resuscitation Research, The Bronx, New York
- Center for Resuscitation Science
| | - Katherine M. Berg
- Center for Resuscitation Science
- Division of Pulmonary, Critical Care, and Sleep Medicine
| | | | - Lakshman Balaji
- Center for Resuscitation Science
- Department of Emergency Medicine, and
| | | | - Michael N. Cocchi
- Center for Resuscitation Science
- Department of Emergency Medicine, and
| | - Maureen Chase
- Center for Resuscitation Science
- Department of Emergency Medicine, and
| | - Michelle Ng Gong
- Division of Critical Care Medicine, Montefiore Medical Center, The Bronx, New York
- Bronx Center for Critical Care Outcomes and Resuscitation Research, The Bronx, New York
| | - Jonathan Gong
- Department of Emergency Medicine, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York; and
| | - Samir M. Parikh
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Michael W. Donnino
- Center for Resuscitation Science
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Department of Emergency Medicine, and
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27
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Han CY, Wang X, Ringgold KM, Bennett JC, St John AE, Berenson R, Stern SA, White NJ. A novel melanocortin fusion protein inhibits fibrinogen oxidation and degradation during trauma-induced coagulopathy. Blood 2023; 142:724-741. [PMID: 37363829 DOI: 10.1182/blood.2022019164] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 05/04/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
Immune cell inflammation is implicated in the pathophysiology of acute trauma-induced coagulopathy (TIC). We hypothesized that leukocyte inflammation contributes to TIC through the oxidation and proteolysis of fibrinogen. To test this hypothesis, antioxidants and a novel anti-inflammatory melanocortin fusion protein (AQB-565) were used to study the effects of interleukin-6 (IL-6)-stimulated human leukocytes on fibrinogen using single-cell imaging flow cytometry and multiplex fluorescent western blotting. We also studied the effects of AQB-565 on fibrinogen using an in vivo rat trauma model of native TIC. IL-6 induced cellular inflammation and mitochondrial superoxide production in human monocytes, causing fibrinogen oxidation and degradation in vitro. Antioxidants suppressing mitochondrial superoxide reduced oxidative stress and inflammation and protected fibrinogen. AQB-565 decreased inflammation, inhibited mitochondrial superoxide, and protected fibrinogen in vitro. Trauma with hemorrhagic shock increased IL-6 and other proinflammatory cytokines and chemokines, selectively oxidized and degraded fibrinogen, and induced TIC in rats in vivo. AQB-565, given at the onset of hemorrhage, blocked inflammation, protected fibrinogen from oxidation and degradation, and prevented TIC. Leukocyte activation contributes to TIC through the oxidation and degradation of fibrinogen, which involves mitochondrial superoxide and cellular inflammation. Suppression of inflammation by activation of melanocortin pathways may be a novel approach for the prevention and treatment of TIC.
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Affiliation(s)
- Chang Yeop Han
- Department of Emergency Medicine and Resuscitation Engineering Science Unit, University of Washington School of Medicine, Seattle, WA
| | - Xu Wang
- Department of Emergency Medicine and Resuscitation Engineering Science Unit, University of Washington School of Medicine, Seattle, WA
| | - Kristyn M Ringgold
- Department of Emergency Medicine and Resuscitation Engineering Science Unit, University of Washington School of Medicine, Seattle, WA
| | - Jennifer C Bennett
- Department of Emergency Medicine and Resuscitation Engineering Science Unit, University of Washington School of Medicine, Seattle, WA
| | - Alexander E St John
- Department of Emergency Medicine and Resuscitation Engineering Science Unit, University of Washington School of Medicine, Seattle, WA
| | | | - Susan A Stern
- Department of Emergency Medicine and Resuscitation Engineering Science Unit, University of Washington School of Medicine, Seattle, WA
| | - Nathan J White
- Department of Emergency Medicine and Resuscitation Engineering Science Unit, University of Washington School of Medicine, Seattle, WA
- Bloodworks Northwest Research Institute, Seattle, WA
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28
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Liang H, Mu Q, Sun W, Liu L, Qiu S, Xu Z, Cui Y, Yan Y, Sun T. Effect of intravenous vitamin C on adult septic patients: a systematic review and meta-analysis. Front Nutr 2023; 10:1211194. [PMID: 37599680 PMCID: PMC10437115 DOI: 10.3389/fnut.2023.1211194] [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: 04/24/2023] [Accepted: 07/06/2023] [Indexed: 08/22/2023] Open
Abstract
Background An increasing number of studies indicate that vitamin C (VC) reduces the mortality of adult septic patients, while some articles suggest otherwise. We performed this systematic review and meta-analysis to resolve the discrepancies in reported results concerning the efficacy of VC in septic patients. Methods We comprehensively searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled trials for randomized controlled trials (RCTs) evaluating the efficacy of intravenous VC (IVVC) on adult septic patients published from inception to November 28, 2022. The quality of outcomes for eligible studies was assessed using the Recommendations Assessment, Development, and Evaluation methodology. The results were analyzed using the pooled mean difference (MD) or risk ratio (RR) and 95% confidence intervals (CIs). Results Twenty-two studies (3,570 adult septic patients) were included. IVVC treatment did not improve 28-day mortality compared to the control group (RR, 0.92; 95% CI, 0.81-1.04; I2 = 26%; evidence risk, moderate). IVVC monotherapy decreased mortality (RR, 0.69; 95% CI, 0.52-0.93; I2 = 57%), whereas combination therapy did not affect mortality (RR, 1.03; 95% CI, 0.90-1.17; I2 =0%). IVVC had a trend to decrease the mortality of septic patients (RR, 0.83; 95% CI, 0.69-1.00; I2 = 33%) but did not affect septic shock patients (RR, 1.01; 95% CI, 0.85-1.21; I2 = 18%). IVVC reduced the duration of vasopressor use (MD, -8.45; 95% CI, -15.43 to -1.47; evidence risk, very low) but did not influence the incidence of AKI, ICU length of stay, duration of mechanical ventilation. Conclusions IVVC treatment did not improve the 28-day mortality in septic patients. Subgroup analysis indicated that VC had a trend to decrease the 28-day mortality in patients with sepsis but not septic shock. IVVC monotherapy, rather than combination therapy, decreased the 28-day mortality in septic patients. The findings imply that Hydrocortisone, Ascorbic acid, Thiamine (HAT) combination therapy is not superior to IVVC monotherapy for septic patients. These findings warrant further confirmation in future studies, which should also investigate the mechanisms underlying the enhanced efficacy of IVVC monotherapy in septic patients. Systematic review registration https://inplasy.com/.
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Affiliation(s)
- Huoyan Liang
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Qingqing Mu
- Academy of Clinical Medicine, Zhengzhou University, Zhengzhou, China
| | - Wenju Sun
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Liming Liu
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Simin Qiu
- Academy of Clinical Medicine, Zhengzhou University, Zhengzhou, China
| | - Zili Xu
- Academy of Clinical Medicine, Zhengzhou University, Zhengzhou, China
| | - Yuqing Cui
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Yan
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
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Lou X, Xue J, Shao R, Mo C, Wang F, Chen G. Postbiotics as potential new therapeutic agents for sepsis. BURNS & TRAUMA 2023; 11:tkad022. [PMID: 37334140 PMCID: PMC10271603 DOI: 10.1093/burnst/tkad022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/01/2023] [Indexed: 06/20/2023]
Abstract
Sepsis is the main cause of death in critically ill patients and gut microbiota dysbiosis plays a crucial role in sepsis. On the one hand, sepsis leads to the destruction of gut microbiota and induces and aggravates terminal organ dysfunction. On the other hand, the activation of pathogenic gut flora and the reduction in beneficial microbial products increase the susceptibility of the host to sepsis. Although probiotics or fecal microbiota transplantation preserve gut barrier function on multiple levels, their efficacy in sepsis with intestinal microbiota disruptions remains uncertain. Postbiotics consist of inactivated microbial cells or cell components. They possess antimicrobial, immunomodulatory, antioxidant and antiproliferative activities. Microbiota-targeted therapy strategies, such as postbiotics, may reduce the incidence of sepsis and improve the prognosis of patients with sepsis by regulating gut microbial metabolites, improving intestinal barrier integrity and changing the composition of the gut microbiota. They offer a variety of mechanisms and might even be superior to more conventional 'biotics' such as probiotics and prebiotics. In this review, we present an overview of the concept of postbiotics and summarize what is currently known about postbiotics and their prospective utility in sepsis therapy. Overall, postbiotics show promise as a viable adjunctive therapy option for sepsis.
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Affiliation(s)
- Xiran Lou
- Medical School, Kunming University of Science and Technology, 727 Jingming South Road, Chenggong District, Kunming 650500, China
| | - Jinfang Xue
- Medical School, Kunming University of Science and Technology, 727 Jingming South Road, Chenggong District, Kunming 650500, China
| | - Ruifei Shao
- Medical School, Kunming University of Science and Technology, 727 Jingming South Road, Chenggong District, Kunming 650500, China
| | - Chunyan Mo
- Medical School, Kunming University of Science and Technology, 727 Jingming South Road, Chenggong District, Kunming 650500, China
| | - Fuping Wang
- Department of Emergency Medicine, The First People's Hospital of Yunnan Province, 157 Jinbi Road, Xishan District, Kunming 650034, China
| | - Guobing Chen
- Department of Emergency Medicine, The First People's Hospital of Yunnan Province, 157 Jinbi Road, Xishan District, Kunming 650034, China
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Lankadeva YR. LOVIT or leave it: The vitamin C debate continues. CRIT CARE RESUSC 2023; 25:63-64. [PMID: 37876602 PMCID: PMC10581254 DOI: 10.1016/j.ccrj.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- Yugeesh R. Lankadeva
- Corresponding author at: Preclinical Critical Care Unit Florey Institute of Neuroscience and Mental Health, University of Melbourne 30 Royal Parade, Parkville, Victoria, 3052, Australia, Tel.: +61 (3) 8334 0417, +61 (4) 0664 9976 (mobile).
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Mohamed A, Abdelaty M, Saad MO, Shible A, Mitwally H, Akkari AR, Elbuzidi A, Bintaher A, Hashim A, Abdelrahim M, Afzal M, El-Enany R, El-Hamid M, Bakdach D, Karic E, Shehatta A, Ibrahim AS, Lance M, Hssain AA, Hassan I. EVALUATION OF HYDROCORTISONE, VITAMIN C, AND THIAMINE FOR THE TREATMENT OF SEPTIC SHOCK: A RANDOMIZED CONTROLLED TRIAL (THE HYVITS TRIAL). Shock 2023; 59:697-701. [PMID: 36870070 PMCID: PMC10125121 DOI: 10.1097/shk.0000000000002110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/21/2023] [Indexed: 03/06/2023]
Abstract
ABSTRACT Purpose: The aim of the study is to evaluate the effect of combined hydrocortisone, vitamin C, and thiamine (triple therapy) on the mortality of patients with septic shock. Methods : This multicenter, open-label, two-arm parallel-group, randomized controlled trial was conducted in four intensive care units in Qatar. Adult patients diagnosed with septic shock requiring norepinephrine at a rate of ≥0.1 μg/kg/min for ≥6 h were randomized to a triple therapy group or a control group. The primary outcome was in-hospital mortality at 60 days or at discharge, whichever occurred first. Secondary outcomes included time to death, change in Sequential Organ Failure Assessment (SOFA) score at 72 h of randomization, intensive care unit length of stay, hospital length of stay, and vasopressor duration. Results: A total of 106 patients (53 in each group) were enrolled in this study. The study was terminated early because of a lack of funding. The median baseline SOFA score was 10 (interquartile range, 8-12). The primary outcomes were similar between the two groups (triple therapy, 28.3% vs. control, 35.8%; P = 0.41). Vasopressor duration among the survivors was similar between the two groups (triple therapy, 50 h vs. control, 58 h; P = 0.44). Other secondary and safety endpoints were similar between the two groups. Conclusion: Triple therapy did not improve in-hospital mortality at 60 days in critically ill patients with septic shock or reduce the vasopressor duration or SOFA score at 72 h. Trial Registration:ClinicalTrials.gov identifier: NCT03380507. Registered on December 21, 2017.
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Affiliation(s)
- Adham Mohamed
- Saint Luke’s Hospital of Kansas City, Kansas City, Missouri
| | - Mohamed Abdelaty
- Department of Critical Care Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Mohamed O. Saad
- Department of Pharmacy, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Shible
- Pharmacy Department, University of North Carolina Rex Hospital, Raleigh, North Carolina
| | - Hassan Mitwally
- Department of Pharmacy, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdel-Rauof Akkari
- Division of Nephrology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Abdurrahmaan Elbuzidi
- Department of Critical Care Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Awadh Bintaher
- Department of Critical Care Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Hashim
- Department of Critical Care Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohammad Afzal
- Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rasha El-Enany
- Department of Pharmacy, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Maha El-Hamid
- Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Dana Bakdach
- Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Edin Karic
- Department of Critical Care Medicine, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Shehatta
- Department of Critical Care Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Abdul-Salam Ibrahim
- Department of Critical Care Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Marcus Lance
- Department of Anesthesiology and Pain Treatment, Aga Khan University Hospital, Nairobi, Kenya
| | - Ali Ait Hssain
- Department of Critical Care Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ibrahim Hassan
- Department of Critical Care Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
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Suárez-de-la-Rica A, Croes B, Ciudad L, Vallejo I, Mújica J, Díaz-Almirón M, Maseda E. Vitamin C and thiamine for the treatment of refractory septic shock in surgical critically ill patients: a retrospective before-and-after study. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2023; 36:187-192. [PMID: 36440551 PMCID: PMC10066916 DOI: 10.37201/req/107.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/02/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to evaluate whether early vitamin C and thiamine administration was associated with a lower 28-day and in-hospital mortality in surgical critically ill patients with refractory septic shock. METHODS We performed a retrospective before-and-after study on patients with refractory septic shock. According to local protocol, hydrocortisone is initiated in case of refractory septic shock. In January 2017, the protocol was changed and vitamin C and thiamine were included. Patients who were admitted in 2015-2016 and 2017-2018 were included in the control and treatment groups, respectively. The primary end point was 28-day and in-hospital mortality. Secondary end points were ICU mortality, ICU and hospital length of stay, duration of vasopressors and mechanical ventilation, use of renal replacement therapy (RRT), and the modification in serum procalcitonin and SOFA score during the first 72 h. RESULTS A total of 120 patients were included (58 in the treatment group and 62 in the control group). Log-rank test in Kaplan-Meier curves showed lower 28-day and in-hospital mortality over time in the treatment group (p=0.021 and p=0.035, respectively) but it not reached statistical significance in ICU mortality over time (p=0.100). The need of RRT was less frequent in treatment group (17.2% vs. 37.1%, p=0.024). There were no differences in other secondary outcomes. CONCLUSIONS Intravenous vitamin C and thiamine administration in surgical patients with refractory septic shock may be associated with a lower 28-day and in-hospital mortality. Further prospective studies are needed in refractory septic shock.
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Affiliation(s)
| | | | | | | | | | | | - E Maseda
- Emilio Maseda, Department of Anesthesiology and Surgical Critical Care. Hospital Univer-sitario La Paz. Madrid. Spain.
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Liang B, Su J, Shao H, Chen H, Xie B. The outcome of IV vitamin C therapy in patients with sepsis or septic shock: a meta-analysis of randomized controlled trials. Crit Care 2023; 27:109. [PMID: 36915173 PMCID: PMC10012592 DOI: 10.1186/s13054-023-04392-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 03/03/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND To update a meta-analysis of randomized controlled trials (RCTs) and further explore the outcome of IV vitamin C (IVVC) administration in sepsis or septic shock patients. METHODS This study is a meta-analysis of RCTs. The RCTs of vitamin C therapy in sepsis or septic shock were searched in PubMed, EMBASE and Clinical Trials.gov from inception to January 16, 2023. We registered the protocol with PROSPERO (CRD42022354875). The primary outcome was delta Sequential Organ Failure Assessment (SOFA) score at 72-96 h. Two reviewers independently assessed RCTs according to eligibility criteria: (1) study type: RCT; (2) patient population: patients ≥ 18 years with sepsis or septic shock; (3) intervention: IVVC at any doses as monotherapy or combined with thiamine or and hydrocortisone compared with standard of care, no intervention or placebo (defined as control group); (4) the RCT described short-term mortality or SOFA score. Then, two authors independently extracted related information from RCTs. RESULTS Eighteen RCTs (n = 3364 patients) were identified in this meta-analysis. There were significant effects in the delta SOFA score from baseline to 72-96 h (MD, - 0.62; 95% CI, - 1.00 to - 0.25; p = 0.001) and the duration of vasopressor use (MD, - 15.07; 95% CI, - 21.59 to - 8.55; p < 0.00001) with IVVC therapy. Treatment with IVVC was not shown to improve short-term mortality (OR, 0.89; 95% CI, 0.77 to 1.04; p = 0.14); nevertheless, dose at 25-100 mg/kg/d subgroup associated with a significant reduction in short-term mortality (OR, 0.80; 95% CI, 0.65 to 0.97; p = 0.03). An increase adverse event was observed in IVVC therapy (OR, 1.98; 95% CI, 1.06 to 3.68; p = 0.03). CONCLUSION In this meta-analysis, IVVC in sepsis or septic shock patients significantly improved delta SOFA score and reduced the duration of vasopressor use, whereas it was not associated with reduction in short-term mortality and had higher adverse events.
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Affiliation(s)
- Baofang Liang
- Department of Healthcare-associated Infection Management, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, Guangdong, China
| | - Jianwei Su
- Department of Clinical Pharmacy, Dongguan Tungwah Hospital, Dongguan, Guangdong, China
| | - Hanquan Shao
- Department of Critical Care Medicine, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, Guangdong, China
| | - Huiying Chen
- Department of Critical Care Medicine, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, Guangdong, China
| | - Baocheng Xie
- Department of Pharmacy, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, Guangdong, China.
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Wang J, Song Q, Yang S, Wang H, Meng S, Huang L, Li Q, Xu J, Xie J, Huang Y. Effects of hydrocortisone combined with vitamin C and vitamin B1 versus hydrocortisone alone on microcirculation in septic shock patients: A pilot study. Clin Hemorheol Microcirc 2023:CH221444. [PMID: 36911931 PMCID: PMC10357145 DOI: 10.3233/ch-221444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
OBJECTIVE To investigate the effects of hydrocortisone combined with vitamin C and vitamin B1 versus hydrocortisone on sublingual microcirculation in septic shock patients. METHODS This pilot study enrolled septic shock patients admitted to the ICU of a tertiary teaching hospital from February 2019 to January 2020. We randomly assigned the enrolled patients to the treatment group (hydrocortisone combined with vitamin C and vitamin B1 added to standard care) and the control group (hydrocortisone alone added to standard care) in a 1 : 1 ratio. The primary outcome was perfused small vascular density (sPVD) monitored by a sublingual microcirculation imaging system at 24 hours after treatment. RESULTS Twelve patients in the treatment group and ten in the control group completed the study. The baseline characteristics were comparable between the groups. No statistically significant difference was found in the sPVD between the groups at baseline. The sPVD in the treatment group was significantly higher than that in the control group at 4 hours after treatment (mean difference, 7.042; 95% CI, 2.227-11.857; P = 0.009) and 24 hours after treatment (mean difference, 7.075; 95% CI, 2.390-11.759; P = 0.008). CONCLUSIONS Compared with hydrocortisone, hydrocortisone combined with vitamin C and vitamin B1 significantly improves microcirculation in septic shock patients.
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Affiliation(s)
- Jinlong Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Qianwen Song
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Shuhe Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Haofei Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Shanshan Meng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Lili Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Qing Li
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jingyuan Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yingzi Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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Thiamine pharmaconutrition in sepsis: Monotherapy, combined therapy, or neither? Current evidence on safety and efficacy. Nutrition 2023; 109:112000. [PMID: 36913862 DOI: 10.1016/j.nut.2023.112000] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/30/2023] [Accepted: 02/04/2023] [Indexed: 02/25/2023]
Abstract
Sepsis is a life-threatening condition characterized by multiorgan dysfunction due to an exaggerated host response to infection associated with a homeostatic failure. In sepsis, different interventions, aimed at improving clinical outcomes, have been tested over the past decades. Among these most recent strategies, intravenous high-dose micronutrients (vitamins and/or trace elements) have been investigated. According to current knowledge, sepsis is characterized by low thiamine levels, which are associated with illness severity, hyperlactatemia, and poor clinical outcomes. However, caution is needed about the clinical interpretation of thiamine blood concentration in critically ill patients, and the inflammatory status, based on C-reactive protein levels, should always be measured. In sepsis, parenteral thiamine has been administered as monotherapy or in combination with vitamin C and corticosteroids. Nevertheless, most of those trials failed to report clinical benefits with high-dose thiamine. The purpose of this review is to summarize the biological properties of thiamine and to examine current knowledge regarding the safety and efficacy of high-dose thiamine as pharmaconutrition strategy when administering singly or in combination with other micronutrients in critically ill adult patients with sepsis or septic shock. Our examination of the most up-to-date evidence concludes that Recommended Daily Allowance supplementation is relatively safe for thiamine-deficient patients. However, current evidence does not support pharmaconutrition with high-dose thiamine as a single therapy or as combination therapy aimed at improving clinical outcomes in critically ill septic patients. The best nutrient combination still needs to be determined, based on the antioxidant micronutrient network and the multiple interactions among different vitamins and trace elements. In addition, a better understanding of the pharmacokinetic and pharmacodynamic profiles of intravenous thiamine is needed. Future well-designed and powered clinical trials are urgently warranted before any specific recommendations can be made regarding supplementation in the critical care setting.
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Kanjee Z, Berg K, Bell TD, Reynolds EE. How Would You Resuscitate This Patient With Septic Shock? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2023; 176:253-259. [PMID: 36780653 DOI: 10.7326/m22-3385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
Sepsis is a potentially life-threatening systemic dysregulatory response to infection, and septic shock occurs when sepsis leads to systemic vasodilation and subsequent tissue hypoperfusion. The Surviving Sepsis Campaign published updated guidelines in 2021 on the management of sepsis and septic shock. Here, in the context of a patient with septic shock, 2 critical care specialists discuss and debate conditional guideline recommendations on using lactate to guide resuscitation, the use of balanced crystalloids versus normal saline, and the use of corticosteroids.
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Affiliation(s)
- Zahir Kanjee
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., E.E.R.)
| | - Katherine Berg
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (K.B.)
| | - Taison D Bell
- Division of Pulmonary and Critical Care Medicine, and Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia (T.D.B.)
| | - Eileen E Reynolds
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., E.E.R.)
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Li M, Ching TH, Hipple C, Lopez R, Sahibzada A, Rahman H. Use of Intravenous Vitamin C in Critically Ill Patients With COVID-19 Infection. J Pharm Pract 2023; 36:60-66. [PMID: 34098784 DOI: 10.1177/08971900211015052] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The pathophysiology for Coronavirus Disease 2019 (COVID-19) infection is characterized by cytokine oxidative stress and endothelial dysfunction. Intravenous (IV) vitamin C has been utilized as adjuvant therapy in critically ill patients with sepsis for its protective effects against reactive oxygen species and immunomodulatory effects. The primary objective of this study was to evaluate the effects of IV vitamin C in critically ill patients with COVID-19 infection. METHODS Retrospective observational cohort study with propensity score matching of intensive care unit (ICU) patients who received 1.5 grams IV vitamin C every 6 hours for up to 4 days for COVID-19 infection. The primary study outcome was in-hospital mortality. Secondary outcomes included vasopressor requirements in norepinephrine equivalents, ICU length of stay, and change in Sequential Organ Failure Assessment (SOFA) score. RESULTS Eight patients received IV vitamin C and were matched to 24 patients. Patients in the IV vitamin C group had higher rates of hospital mortality [7 (88%) vs. 19 (79%), P = 0.049]. There was no difference in the daily vasopressor requirement in the treatment group or between the 2 groups. The mean SOFA scores post-treatment was higher in the IV vitamin C group (12.4 ± 2.8 vs. 8.1 ± 3.5, P < 0.005). There was no difference in ICU length of stay between the treatment and control groups. CONCLUSION Adjunctive IV vitamin C for the management of COVID-19 infection in critically ill patients may not decrease the incidence of mortality, vasopressor requirements, SOFA scores, or ventilator settings.
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Affiliation(s)
- Matthew Li
- New York City Health + Hospitals/Queens, Jamaica, NY, USA
| | - Tsung Han Ching
- New York City Health + Hospitals/Queens, Jamaica, NY, USA.,5925Icahn School of Medicine at Mount Sinai, NY, USA
| | | | - Ricardo Lopez
- New York City Health + Hospitals/Queens, Jamaica, NY, USA.,5925Icahn School of Medicine at Mount Sinai, NY, USA
| | - Asad Sahibzada
- New York City Health + Hospitals/Queens, Jamaica, NY, USA.,5925Icahn School of Medicine at Mount Sinai, NY, USA
| | - Habibur Rahman
- New York City Health + Hospitals/Queens, Jamaica, NY, USA.,5925Icahn School of Medicine at Mount Sinai, NY, USA
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High-Dose IV Hydroxocobalamin (Vitamin B12) in Septic Shock: A Double-Blind, Allocation-Concealed, Placebo-Controlled Single-Center Pilot Randomized Controlled Trial (The Intravenous Hydroxocobalamin in Septic Shock Trial). Chest 2023; 163:303-312. [PMID: 36174744 DOI: 10.1016/j.chest.2022.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/22/2022] [Accepted: 09/06/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Elevated hydrogen sulfide (H2S) contributes to vasodilatation and hypotension in septic shock, and traditional therapies do not target this pathophysiologic mechanism. High-dose IV hydroxocobalamin scavenges and prevents H2S formation, which may restore vascular tone and may accentuate recovery. No experimental human studies have tested high-dose IV hydroxocobalamin in adults with septic shock. RESEARCH QUESTION In adults with septic shock, is comparing high-dose IV hydroxocobalamin with placebo feasible? STUDY DESIGN AND METHODS We conducted a phase 2 single-center, double-blind, allocation-concealed, placebo-controlled, parallel-group pilot randomized controlled trial comparing high-dose IV hydroxocobalamin with placebo in critically ill adults with septic shock. Patients meeting Sepsis 3 criteria were randomized 1:1 to receive a single 5-g dose of high-dose IV hydroxocobalamin or equivalent volume 0.9% saline solution as placebo. The primary outcome was study feasibility (enrollment rate, clinical and laboratory compliance rate, and contamination rate). Secondary outcomes included between-group differences in plasma H2S concentrations and vasopressor dose before and after infusion. RESULTS Twenty patients were enrolled over 19 months, establishing an enrollment rate of 1.05 patients per month. Protocol adherence rates were 100% with zero contamination. In the high-dose IV hydroxocobalamin group, compared to placebo, there was a greater reduction in vasopressor dose between randomization and postinfusion (-36% vs 4%, P < .001) and randomization and 3-h postinfusion (-28% vs 10%, P = .019). In the high-dose IV hydroxocobalamin group, the plasma H2S level was reduced over 45 mins by -0.80 ± 1.73 μM, as compared with -0.21 ± 0.64 μM in the placebo group (P = .3). INTERPRETATION This pilot trial established favorable feasibility metrics. Consistent with the proposed mechanism of benefit, high-dose IV hydroxocobalamin compared with placebo was associated with reduced vasopressor dose and H2S levels at all time points and without serious adverse events. These data provide the first proof of concept for feasibility of delivering high-dose IV hydroxocobalamin in septic shock. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03783091; URL: www. CLINICALTRIALS gov.
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Williams Roberson S, Nwosu S, Collar EM, Kiehl A, Harrison FE, Bastarache J, Wilson JE, Mart MF, Sevransky JE, Ely EW, Lindsell CJ, Jackson JC. Association of Vitamin C, Thiamine, and Hydrocortisone Infusion With Long-term Cognitive, Psychological, and Functional Outcomes in Sepsis Survivors: A Secondary Analysis of the Vitamin C, Thiamine, and Steroids in Sepsis Randomized Clinical Trial. JAMA Netw Open 2023; 6:e230380. [PMID: 36853612 PMCID: PMC9975932 DOI: 10.1001/jamanetworkopen.2023.0380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/02/2023] [Indexed: 03/01/2023] Open
Abstract
Importance Sepsis is associated with long-term cognitive impairment and worse psychological and functional outcomes. Potential mechanisms include intracerebral oxidative stress and inflammation, yet little is known about the effects of early antioxidant and anti-inflammatory therapy on cognitive, psychological, and functional outcomes in sepsis survivors. Objective To describe observed differences in long-term cognitive, psychological, and functional outcomes of vitamin C, thiamine, and hydrocortisone between the intervention and control groups in the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) randomized clinical trial. Design, Setting, and Participants This prespecified secondary analysis reports the 6-month outcomes of the multicenter, double-blind, placebo-controlled VICTAS randomized clinical trial, which was conducted between August 2018 and July 2019. Adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction who survived to discharge or day 30 were recruited from 43 intensive care units in the US. Participants were randomized 1:1 to either the intervention or control group. Cognitive, psychological, and functional outcomes at 6 months after randomization were assessed via telephone through January 2020. Data analyses were conducted between February 2021 and December 2022. Interventions The intervention group received intravenous vitamin C (1.5 g), thiamine hydrochloride (100 mg), and hydrocortisone sodium succinate (50 mg) every 6 hours for 96 hours or until death or intensive care unit discharge. The control group received matching placebo. Main Outcomes and Measures Cognitive performance, risk of posttraumatic stress disorder and depression, and functional status were assessed using a battery of standardized instruments that were administered during a 1-hour telephone call 6 months after randomization. Results After exclusions, withdrawals, and deaths, the final sample included 213 participants (median [IQR] age, 57 [47-67] years; 112 males [52.6%]) who underwent long-term outcomes assessment and had been randomized to either the intervention group (n = 108) or control group (n = 105). The intervention group had lower immediate memory scores (adjusted OR [aOR], 0.49; 95% CI, 0.26-0.89), higher odds of posttraumatic stress disorder (aOR, 3.51; 95% CI, 1.18-10.40), and lower odds of receiving mental health care (aOR, 0.38; 95% CI, 0.16-0.89). No other statistically significant differences in cognitive, psychological, and functional outcomes were found between the 2 groups. Conclusions and Relevance In survivors of sepsis, treatment with vitamin C, thiamine, and hydrocortisone did not improve or had worse cognitive, psychological, and functional outcomes at 6 months compared with patients who received placebo. These findings challenge the hypothesis that antioxidant and anti-inflammatory therapy during critical illness mitigates the development of long-term cognitive, psychological, and functional impairment in sepsis survivors. Trial Registration ClinicalTrials.gov Identifier: NCT03509350.
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Affiliation(s)
- Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erin M. Collar
- Critical Illness, Brain Dysfunction and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy Kiehl
- Critical Illness, Brain Dysfunction and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Fiona E. Harrison
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Brain Institute, Vanderbilt University, Nashville, Tennessee
| | - Julie Bastarache
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Brain Institute, Vanderbilt University, Nashville, Tennessee
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
- Veteran’s Affairs Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Matthew F. Mart
- Critical Illness, Brain Dysfunction and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Veteran’s Affairs Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Jonathan E. Sevransky
- Division of Pulmonary, Allergy Critical Care and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Veteran’s Affairs Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | | | - James C. Jackson
- Critical Illness, Brain Dysfunction and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Veteran’s Affairs Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
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Blakeslee PA, Hyrkäs K. Impact of supplemental thiamin on lactate levels in adults with septic shock. Nutr Clin Pract 2023; 38:580-601. [PMID: 36633131 DOI: 10.1002/ncp.10930] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 09/09/2022] [Accepted: 10/09/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Elevated lactate levels at 24 h are highly predictive of in-hospital mortality in adults with septic shock. Thiamin is closely involved in carbohydrate metabolism, and in thiamin-deficient states, increased lactic acid levels can be found, exacerbated by critical illness. This integrative literature review focused on the relationship between supplemental thiamin, lactate clearance, and impact on mortality in sepsis. METHODS A search in PubMed, Embase, and CINAHL was conducted for literature published between January 2016 and January 2021. We included observational studies and clinical trials with ≥10 participants. We excluded studies involving pediatric (<18 years old) populations, animal studies, case studies, dropout rate of >20%, nonhospitalized patients, or patients receiving comfort measures only. RESULTS A total of 48 full-text articles were assessed for eligibility, with 15 evaluated for this integrative review. Included were five retrospective, two prospective observational, and eight randomized controlled trials. In almost all retrospective studies, thiamin administration was associated with decreased mortality, and in observational studies, with decreased lactate and improved clinical outcomes. In clinical trials, thiamin with or without vitamin C/hydrocortisone did not impact clinical outcomes or mortality. However, four trials testing intravenous thiamin 200-500 mg two to three times daily for up to 3 days reported improved lactate clearance. CONCLUSIONS Thiamin supplementation may improve lactate clearance when administered in the first 24 h. Those deficient in thiamin may benefit more from supplementation. The combination of thiamin, vitamin C, and/or hydrocortisone may not be advantageous. Lactate reduction in response to thiamin needs further rigorous research.
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Affiliation(s)
- Paul A Blakeslee
- Clinical Nutrition Program, Maine Medical Center, Portland, Maine, USA
| | - Kristiina Hyrkäs
- Center for Nursing Research and Quality Outcomes, Maine Medical Center, Portland, Maine, USA
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Winters ME, Hu K, Martinez JP, Mallemat H, Brady WJ. The critical care literature 2021. Am J Emerg Med 2023; 63:12-21. [PMID: 36306647 DOI: 10.1016/j.ajem.2022.10.025] [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: 08/16/2022] [Revised: 10/01/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
An emergency physician (EP) is often the first provider to evaluate, resuscitate, and manage a critically ill patient. Over the past two decades, the annual hours of critical care delivered in emergency departments across the United States has dramatically increased. During the period from 2006 to 2014, the extent of critical care provided in the emergency department (ED) to critically ill patients increased approximately 80%. During the same time period, the number of intubated patients cared for in the ED increased by approximately 16%. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. Prolonged ED boarding times for critically ill patients is associated with increased duration of mechanical ventilation, increased intensive care unit (ICU) length of stay, increased hospital length of stay, increased medication-related adverse events, and increased in-hospital, 30-day, and 90-day mortality. As a result, it is imperative for the EP to be knowledgeable about recent developments in resuscitation and critical care medicine, so that the critically ill ED patient care receive current evidence-based care. These articles have been selected based on the authors review of key critical care, resuscitation, emergency medicine, and medicine journals and their opinion of the importance of study findings as it pertains to the care of the critically ill ED patient. Topics covered in this article include cardiac arrest, post-cardiac arrest care, rapid sequence intubation, mechanical ventilation, fluid resuscitation, cardiogenic shock, transfusions, and sepsis.
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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
- Internal Medicine and Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - William J Brady
- Departments of Emergency Medicine and Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
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Wen C, Li Y, Hu Q, Liu H, Xu X, Lü M. IV Vitamin C in Sepsis: A Latest Systematic Review and Meta-Analysis. Int J Clin Pract 2023; 2023:6733465. [PMID: 36743822 PMCID: PMC9889164 DOI: 10.1155/2023/6733465] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/21/2022] [Accepted: 01/04/2023] [Indexed: 01/26/2023] Open
Abstract
Sepsis is a high-incidence disease and demands intensive care. Finding effective treatment is the key to cure sepsis. Studies have shown a lower level of vitamin C in patients with sepsis. Therefore, vitamin C supplementation has become one of the measures to treat sepsis. However, the clinical studies of vitamin C in the treatment of sepsis have been controversial. We performed a meta-analysis to evaluate vitamin C's efficacy and safety in the treatment of sepsis. We searched four electronic databases: PubMed, Embase, Web of Science, and the Cochrane Library, and two researchers independently screened 24 eligible RCTs published in English. Our review demonstrates that intravenous (IV) vitamin C might improve short-term mortality (RR, 0.82; 95% CI, 0.65-1.02; P=0.07; and I 2 = 45%) and overall mortality (RR, 0.86; 95% CI, 0.74-1.01; P=0.06; and I 2 = 51%) of patients with sepsis. Moreover, the SOFA score of patients with sepsis improved significantly after treatment with vitamin C for over 72 hours (RR, 0.26; 95% CI, 0.09-0.42; P=0.002; and I 2 = 0%). The main results of our study were moderate-quality evidence. More high-quality, multicenter RCTs are needed to provide more substantial evidence on the efficacy and safety of IV vitamin C for sepsis.
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Affiliation(s)
- Chengli Wen
- Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Jiangyang District, Luzhou, Sichuan, China
| | - Yuan Li
- Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Jiangyang District, Luzhou, Sichuan, China
| | - Qinxue Hu
- Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Jiangyang District, Luzhou, Sichuan, China
| | - Hui Liu
- Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Jiangyang District, Luzhou, Sichuan, China
| | - Xinxin Xu
- Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Jiangyang District, Luzhou, Sichuan, China
| | - Muhan Lü
- Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Jiangyang District, Luzhou, Sichuan, China
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Muacevic A, Adler JR, Sevilla L, Garza J, Rashid H, Benitez AC, Shipotko M, Ali Z. A Systematic Review and Meta-Analysis on Possible Role of Vitamin C in Sepsis. Cureus 2022; 14:e32886. [PMID: 36699754 PMCID: PMC9867929 DOI: 10.7759/cureus.32886] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 12/24/2022] Open
Abstract
Sepsis is a substantial healthcare burden, and its management continues to be a major challenge. Prior studies demonstrate conflicting evidence regarding the utility of vitamin C in sepsis. This systematic review and meta-analysis aim to collect data among critically ill patients (sepsis/septic shock), comparing the efficacy of parenteral vitamin C with standard care. A literature review was conducted using databases including PubMed, Web of Science, Google Scholar, and the Cochrane Library to identify randomized controlled trials (RCTs) and observational studies comparing intravenous vitamin C alone or in combination with thiamine or glucocorticoids to the standard of care. We identified 11 RCTs and seven retrospective cohort studies. The primary outcome was 28-day mortality. Secondary outcomes included intensive care unit (ICU) length of stay, change in Sequential Organ Failure Assessment (SOFA) score, duration of vasopressor use, and duration of mechanical ventilation. A total of 18 studies with 4078 patients were included in our final analysis. Overall, we found no mortality reduction in patients treated with vitamin C compared to standard of care (odds ratio (OR) 0.92; 95% confidence interval (CI) 0.78 to 1.09; p = 0.34). Studies that reported a change in SOFA scores, ICU length of stay, duration of mechanical ventilation, or duration of vasopressor use did not show any significant difference between groups. Subgroup analysis with RCT versus observational studies and vitamin C dosage regimens did not show any difference. Among patients with sepsis or septic shock, treatment with vitamin C was not associated with a reduction in mortality, ICU length of stay, change in SOFA score, duration of vasopressor use, or duration of mechanical ventilation. Further studies are needed to demonstrate the potential role of vitamin C in the management of sepsis.
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Wieruszewski PM, Brickett LM, Dayal L, Egan AM, Khanna AK, Lemieux SM, Mukkera SR, Patel JS, Reichert MJ, Reynolds TR, Sen P, Thornton NM, Turpin GM, Winter JB, Bissell BD. Major Publications in the Critical Care Pharmacotherapy Literature: 2021. Crit Care Explor 2022; 4:e0823. [PMID: 36567788 PMCID: PMC9760627 DOI: 10.1097/cce.0000000000000823] [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: 12/23/2022] Open
Abstract
To summarize the most impactful articles relevant to the pharmacotherapy of critically ill adult patients published in 2021. DATA SOURCE PubMed/MEDLINE. STUDY SELECTION Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critical care patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2021, and December 31, 2021. DATA EXTRACTION Candidate articles were organized by clinical domain based on the emerging themes from all studies. A modified Delphi process was applied to obtain consensus on the most impactful publication within each clinical domain based on overall contribution to scientific knowledge and novelty to the literature. DATA SYNTHESIS The search revealed 830 articles, of which 766 were excluded leaving 64 candidate articles for the Delphi process. These 64 articles were organized by clinical domain including: emergency/neurology, cardiopulmonary, nephrology/fluids, infectious diseases, metabolic, immunomodulation, and nutrition/gastroenterology. Each domain required the a priori defined three Delphi rounds. The resultant most impactful articles from each domain included five randomized controlled trials and two systematic review/meta-analyses. Topics studied included sedation during mechanical ventilation, anticoagulation in COVID-19, extended infusion beta-lactams, interleukin-6 antagonists in COVID-19, balanced crystalloid resuscitation, vitamin C/thiamine/hydrocortisone in sepsis, and promotility agents during enteral feeding. CONCLUSIONS This synoptic review provides a summary and perspective of the most impactful articles relevant to the pharmacotherapy of critically ill adults published in 2021.
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Affiliation(s)
| | | | | | - Ashley M Egan
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Ashish K Khanna
- Department of Anesthesiology, Section of Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | | | | | | | | | | | - Parijat Sen
- Division of Pulmonary and Critical Care, University of Kentucky, Lexington, KY
| | | | | | - Jessica B Winter
- UC Health, University of Cincinnati Medical Center, Cincinnati, OH
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Jin L, Liao W, Zhou X, Wang Y, Qian J. Hydrocortisone alleviates sepsis-induced acute kidney injury through HSF-1-mediated transcriptional suppression of XPO1. Tissue Cell 2022; 79:101915. [DOI: 10.1016/j.tice.2022.101915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/28/2022] [Accepted: 08/30/2022] [Indexed: 11/15/2022]
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Wang D, Wang J, Zheng X, Diao S, Li W, Ma W. Bone homeostasis disorders increased the mortality of sepsis patients: A preliminary retrospective cohort study. Front Med (Lausanne) 2022; 9:1017411. [DOI: 10.3389/fmed.2022.1017411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022] Open
Abstract
IntroductionSepsis is a common clinical syndrome and nearly 20% of all deaths are related to sepsis. As an important part of the body, bone homeostasis disorders are closely related to inflammatory response, but the correlation between bone homeostasis and sepsis, sepsis shock was unknown. The objective of this study was to explore the relation of bone homeostasis on sepsis and sepsis shock.MethodsIn this retrospective cohort study, patients were enrolled between April 2018 and May 2022 from Beijing Chaoyang hospital. Primary outcomes were serum indicators reflected bone homeostasis, such as cross-linked carboxy-terminal telopeptide of type I collagen (CTX-I), tartrate-resistant acid phosphatase 5b (TRACP-5b) and piezo-type mechanosensitive ion channel component 1 (PIEZO1).ResultsThe data were analyzed retrospectively. among 88 evaluable patients, 45 were sepsis (19 were sepsis shock) and 43 were non-sepsis. There was no significant difference in age, gender, BMI, combination diseases, operation time, intraoperative blood loss, and hospital stay. Patients with sepsis or sepsis shock had higher serum CTX-I, TRACP-5b, PIEZO1 (p < 0.05). Spearman’s rank correlation test showed that CTX-I, TRACP-5b, PIEZO1 and the three together (CTX-I + TRACP-5b + PIEZO1) had strong correlation with sepsis or sepsis shock (p < 0.05). The receiver operating characteristic curve (ROC) and precision-recall curve (PRC) showed that these indicators could predict the occurrence of sepsis or sepsis shock (p < 0.05). Besides, decision curve analysis (DCA) and interventions avoided curve (IAC) displayed a high net benefit of bone homeostasis disorders indicators on sepsis or sepsis shock. Kaplan–Meier survival curves revealed that sepsis or shock patients with high value indicators (>0.47227) had a higher mortality (p < 0.05).ConclusionBone homeostasis disorders could increase the mortality of sepsis and sepsis shock patients.
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The revised recommendation for administering vitamin C in septic patients: the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020. J Intensive Care 2022; 10:50. [PMID: 36447298 PMCID: PMC9706956 DOI: 10.1186/s40560-022-00641-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Given the available clinical evidence through the literature search when the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 was being created, we suggested administering vitamin C to such patients. Recently, several randomized control trials have been published, some of which suggested the harmful effect of vitamin C in terms of mortality or persistent organ dysfunction. Therefore, we performed updated systematic reviews and meta-analyses. Accordingly, we revised our recommendation as "We suggest against administering vitamin C to septic patients (GRADE 2D: certainty of evidence = "very low")."
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Juneja D, Nasa P, Jain R. Current role of high dose vitamin C in sepsis management: A concise review. World J Crit Care Med 2022; 11:349-363. [PMID: 36439321 PMCID: PMC9693906 DOI: 10.5492/wjccm.v11.i6.349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/08/2022] [Accepted: 09/09/2022] [Indexed: 02/05/2023] Open
Abstract
Sepsis and septic shock are common diagnoses for patients requiring intensive care unit admission and associated with high morbidity and mortality. In addition to aggressive fluid resuscitation and antibiotic therapy, several other drugs have been tried as adjuvant therapies to reduce the inflammatory response and improve outcomes. Vitamin C has been shown to have several biological actions, including anti-inflammatory and immunomodulatory effects, which may prove beneficial in sepsis management. Initial trials showed improved patient outcomes when high dose vitamin C was used in combination with thiamine and hydrocortisone. These results, along with relative safety of high-dose (supra-physiological) vitamin C, encouraged physicians across the globe to add vitamin C as an adjuvant therapy in the management of sepsis. However, subsequent large-scale randomised control trials could not replicate these results, leaving the world divided regarding the role of vitamin C in sepsis management. Here, we discuss the rationale, safety profile, and the current clinical evidence for the use of high-dose vitamin C in the management of sepsis and septic shock.
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Affiliation(s)
- Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | - Ravi Jain
- Department of Critical Care Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur 302022, Rajasthan, India
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Chen CY, Chiu CT, Lee HS, Lai CC. The impact of vitamin C-containing treatment on the mortality of patients with sepsis: a systematic review and meta-analysis of randomized controlled trials. J Infect Public Health 2022; 15:1514-1520. [DOI: 10.1016/j.jiph.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/22/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022] Open
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Young PJ, Lamontagne F, Fujii T. Vitamin C in sepsis. Intensive Care Med 2022; 48:1621-1624. [PMID: 35960273 DOI: 10.1007/s00134-022-06822-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Paul J Young
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand. .,Medical Research Institute of New Zealand, Wellington, New Zealand. .,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia. .,Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia.
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, 3001 12th Ave. N., Sherbrooke, QC, J1H 5N4, Canada
| | - Tomoko Fujii
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia.,Intensive Care Unit, Jikei University Hospital, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.,Department of Health Promotion and Human Behaviour, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
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