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Schlapbach LJ, Raman S, Buckley D, George S, King M, Ridolfi R, Harley A, Cree M, Long D, Erickson S, Singh P, Festa M, Gibbons K, Bellomo R. Resuscitation With Vitamin C, Hydrocortisone, and Thiamin in Children With Septic Shock: A Multicenter Randomized Pilot Study. Pediatr Crit Care Med 2024; 25:159-170. [PMID: 38240537 PMCID: PMC10793796 DOI: 10.1097/pcc.0000000000003346] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Adjunctive therapy with vitamin C, hydrocortisone, and thiamin has been evaluated in adults, but randomized controlled trial (RCT) data in children are lacking. We aimed to test the feasibility of vitamin C, hydrocortisone, and thiamin in PICU patients with septic shock; and to explore whether the intervention is associated with increased survival free of organ dysfunction. DESIGN Open-label parallel, pilot RCT multicenter study. The primary endpoint was feasibility. Clinical endpoints included survival free of organ dysfunction censored at 28 days and nine secondary outcomes, shock reversal, and two proxy measures of intervention efficacy. SETTING Six PICUs in Australia and New Zealand. PATIENTS Children of age between 28 days and 18 years requiring vasoactive drugs for septic shock between August 2019 and March 2021. INTERVENTIONS Patients were assigned 1:1 to receive 1 mg/kg hydrocortisone every 6 hours (q6h), 30 mg/kg ascorbic acid q6h, and 4 mg/kg thiamin every 12 hours (n = 27), or standard septic shock management (n = 33). MEASUREMENTS AND MAIN RESULTS Sixty of 77 (78%) eligible patients consented with 91% of approached parents providing consent. The median time from randomization to intervention was 44 (interquartile range [IQR] 29-120) min. Seventy of seventy-seven (28%) patients had received IV steroids before randomization. Median survival alive and free of organ dysfunction was 20.0 (0.0-26.0) days in the intervention and 21.0 (0.0-25.0) days in the standard care group. Median PICU length of stay was 5.3 (2.5-11.3) days in the intervention group versus 6.9 (3.0-11.5) days in the control group. Shock reversal occurred at a median of 35.2 (14.6-101.2) hours in the intervention group versus 47.3 (22.4-106.8) hours in the standard care group (median difference -12 hr; 95% CI, -56.8 to 32.7 hr). CONCLUSIONS In children requiring vasopressors for septic shock, a protocol comparing adjunctive treatment with high-dose vitamin C, hydrocortisone, and thiamin versus standard care was feasible. These findings assist in making modifications to the trial protocol to enable a better-designed larger RCT.
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Affiliation(s)
- Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Paediatric Critical Care Unit, Perth Children`s Hospital, Perth, WA, Australia
- Paediatric Intensive Care Unit, Sydney Children's Hospital, Sydney, NSW, Australia
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children's Hospitals Network, Sydney, NSW, Australia
- Intensive Care Research, Austin Hospital and Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne., Melbourne, VIC, Australia
- Australian and New Zealand Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Sainath Raman
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - David Buckley
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
| | - Shane George
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Megan King
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia
| | - Roberta Ridolfi
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Amanda Harley
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, QLD, Australia
| | - Michele Cree
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Debbie Long
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Simon Erickson
- Paediatric Critical Care Unit, Perth Children`s Hospital, Perth, WA, Australia
| | - Puneet Singh
- Paediatric Intensive Care Unit, Sydney Children's Hospital, Sydney, NSW, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children's Hospitals Network, Sydney, NSW, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Rinaldo Bellomo
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Paediatric Critical Care Unit, Perth Children`s Hospital, Perth, WA, Australia
- Paediatric Intensive Care Unit, Sydney Children's Hospital, Sydney, NSW, Australia
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children's Hospitals Network, Sydney, NSW, Australia
- Intensive Care Research, Austin Hospital and Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne., Melbourne, VIC, Australia
- Australian and New Zealand Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
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