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Sevransky JE, Rothman RE, Hager DN, Bernard GR, Brown SM, Buchman TG, Busse LW, Coopersmith CM, DeWilde C, Ely EW, Eyzaguirre LM, Fowler AA, Gaieski DF, Gong MN, Hall A, Hinson JS, Hooper MH, Kelen GD, Khan A, Levine MA, Lewis RJ, Lindsell CJ, Marlin JS, McGlothlin A, Moore BL, Nugent KL, Nwosu S, Polito CC, Rice TW, Ricketts EP, Rudolph CC, Sanfilippo F, Viele K, Martin GS, Wright DW. Effect of Vitamin C, Thiamine, and Hydrocortisone on Ventilator- and Vasopressor-Free Days in Patients With Sepsis: The VICTAS Randomized Clinical Trial. JAMA 2021; 325:742-750. [PMID: 33620405 PMCID: PMC7903252 DOI: 10.1001/jama.2020.24505] [Citation(s) in RCA: 144] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Sepsis is a common syndrome with substantial morbidity and mortality. A combination of vitamin C, thiamine, and corticosteroids has been proposed as a potential treatment for patients with sepsis. OBJECTIVE To determine whether a combination of vitamin C, thiamine, and hydrocortisone every 6 hours increases ventilator- and vasopressor-free days compared with placebo in patients with sepsis. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, double-blind, adaptive-sample-size, placebo-controlled trial conducted in adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction. Participants were enrolled in the emergency departments or intensive care units at 43 hospitals in the United States between August 2018 and July 2019. After enrollment of 501 participants, funding was withheld, leading to an administrative termination of the trial. All study-related follow-up was completed by January 2020. INTERVENTIONS Participants were randomized to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 hours (n = 252) or matching placebo (n = 249) for 96 hours or until discharge from the intensive care unit or death. Participants could be treated with open-label corticosteroids by the clinical team, with study hydrocortisone or matching placebo withheld if the total daily dose was greater or equal to the equivalent of 200 mg of hydrocortisone. MAIN OUTCOMES AND MEASURES The primary outcome was the number of consecutive ventilator- and vasopressor-free days in the first 30 days following the day of randomization. The key secondary outcome was 30-day mortality. RESULTS Among 501 participants randomized (median age, 62 [interquartile range {IQR}, 50-70] years; 46% female; 30% Black; median Acute Physiology and Chronic Health Evaluation II score, 27 [IQR, 20.8-33.0]; median Sequential Organ Failure Assessment score, 9 [IQR, 7-12]), all completed the trial. Open-label corticosteroids were prescribed to 33% and 32% of the intervention and control groups, respectively. Ventilator- and vasopressor-free days were a median of 25 days (IQR, 0-29 days) in the intervention group and 26 days (IQR, 0-28 days) in the placebo group, with a median difference of -1 day (95% CI, -4 to 2 days; P = .85). Thirty-day mortality was 22% in the intervention group and 24% in the placebo group. CONCLUSIONS AND RELEVANCE Among critically ill patients with sepsis, treatment with vitamin C, thiamine, and hydrocortisone, compared with placebo, did not significantly increase ventilator- and vasopressor-free days within 30 days. However, the trial was terminated early for administrative reasons and may have been underpowered to detect a clinically important difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03509350.
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Affiliation(s)
- 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
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David N. Hager
- Division of Pulmonary Critical Care, Johns Hopkins University, Baltimore, Maryland
| | - Gordon R. Bernard
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel M. Brown
- Division of Pulmonary Critical Care, Intermountain Medical Center and University of Utah, Salt Lake City
| | - Timothy G. Buchman
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Laurence W. Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Craig M. Coopersmith
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Christine DeWilde
- Division of Pulmonary Critical Care, Virginia Commonwealth University, Richmond
| | - E. Wesley Ely
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
- Johns Hopkins Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Baltimore, Maryland
- Veteran’s Affairs Tennessee Valley Geriatric Research Education Clinical Center (GRECC), Nashville
| | | | - Alpha A. Fowler
- Division of Pulmonary Critical Care, Virginia Commonwealth University, Richmond
| | - David F. Gaieski
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michelle N. Gong
- Department of Critical Care, Montefiore Medical Center, Bronx, New York
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Michael H. Hooper
- Division of Pulmonary Critical Care, Sentara Healthcare, Norfolk, Virginia
| | - Gabor D. Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Akram Khan
- Division of Pulmonary Critical Care, Oregon Health & Science University, Portland
| | - Mark A. Levine
- Molecular and Clinical Nutrition Section, National Institutes of Health, Bethesda, Maryland
| | - Roger J. Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
- Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Chris J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica S. Marlin
- Vanderbilt Coordinating Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Brooks L. Moore
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | | | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carmen C. Polito
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Todd W. Rice
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erin P. Ricketts
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Fred Sanfilippo
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kert Viele
- Berry Consultants LLC, Austin, Texas
- Department of Biostatistics, University of Kentucky, Lexington
| | - Greg S. Martin
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
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Lindsell CJ, McGlothlin A, Nwosu S, Rice TW, Hall A, Bernard GR, Busse LW, Ely EW, Fowler AA, Gaieski DF, Hinson JS, Hooper MH, Jackson JC, Kelen GD, Levine M, Martin GS, Rothman RE, Sevransky JE, Viele K, Wright DW, Hager DN. In response: Letter on update to the Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) protocol. Trials 2020; 21:351. [PMID: 32317004 PMCID: PMC7175511 DOI: 10.1186/s13063-020-04290-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/28/2020] [Indexed: 11/10/2022] Open
Abstract
TRIAL REGISTRATION ClinicalTrials.gov: NCT03509350. Registered on 26 April 2018.
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Affiliation(s)
| | | | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - Gordon R Bernard
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - E Wesley Ely
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease & Critical Care Medicine, Department of Internal Medicine, The VCU Johnson Center for Critical Care and Pulmonary Research, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael H Hooper
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, VA, USA
| | - James C Jackson
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA.,Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Gabor D Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Levine
- Molecular & Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD, USA
| | - Greg S Martin
- Grady Memorial Hospital, Atlanta, GA, USA.,Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | | | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - David N Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1800 Orleans Street, Suite 9121, Baltimore, MD, 21287, USA
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3
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Lindsell CJ, McGlothlin A, Nwosu S, Rice TW, Hall A, Bernard GR, Busse LW, Ely EW, Fowler AA, Gaieski DF, Hinson JS, Hooper MH, Jackson JC, Kelen GD, Levine M, Martin GS, Rothman RE, Sevransky JE, Viele K, Wright DW, Hager DN. Update to the Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) protocol: statistical analysis plan for a prospective, multicenter, double-blind, adaptive sample size, randomized, placebo-controlled, clinical trial. Trials 2019; 20:670. [PMID: 31801567 PMCID: PMC6894243 DOI: 10.1186/s13063-019-3775-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/09/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Observational research suggests that combined therapy with Vitamin C, thiamine and hydrocortisone may reduce mortality in patients with septic shock. METHODS AND DESIGN The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) trial is a multicenter, double-blind, adaptive sample size, randomized, placebo-controlled trial designed to test the efficacy of combination therapy with vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) given every 6 h for up to 16 doses in patients with respiratory or circulatory dysfunction (or both) resulting from sepsis. The primary outcome is ventilator- and vasopressor-free days with mortality as the key secondary outcome. Recruitment began in August 2018 and is ongoing; 501 participants have been enrolled to date, with a planned maximum sample size of 2000. The Data and Safety Monitoring Board reviewed interim results at N = 200, 300, 400 and 500, and has recommended continuing recruitment. The next interim analysis will occur when N = 1000. This update presents the statistical analysis plan. Specifically, we provide definitions for key treatment and outcome variables, and for intent-to-treat, per-protocol, and safety analysis datasets. We describe the planned descriptive analyses, the main analysis of the primary end point, our approach to secondary and exploratory analyses, and handling of missing data. Our goal is to provide enough detail that our approach could be replicated by an independent study group, thereby enhancing the transparency of the study. TRIAL REGISTRATION ClinicalTrials.gov, NCT03509350. Registered on 26 April 2018.
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Affiliation(s)
| | | | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - Gordon R Bernard
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - E Wesley Ely
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease & Critical Care Medicine, Department of Internal Medicine, The VCU Johnson Center for Critical Care and Pulmonary Research, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael H Hooper
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, VA, USA
| | - James C Jackson
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA.,Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gabor D Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Levine
- Molecular & Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD, USA
| | - Greg S Martin
- Grady Memorial Hospital, Atlanta, GA, USA.,Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | | | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - David N Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1800 Orleans Street, Suite 9121, Baltimore, MD, 21287, USA
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4
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Hager DN, Martin GS, Sevransky JE, Hooper MH. Glucometry When Using Vitamin C in Sepsis: A Note of Caution. Chest 2019; 154:228-229. [PMID: 30044741 DOI: 10.1016/j.chest.2018.03.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/12/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- David N Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD.
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
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5
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Marik PE, Hooper MH, Khangoora V, Rivera R, Catravas J. Response. Chest 2019; 152:690-691. [PMID: 28889895 DOI: 10.1016/j.chest.2017.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 06/22/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Racquel Rivera
- Department of Pharmacy, Sentara Norfolk General Hospital, Norfolk, VA
| | - John Catravas
- Departments of Medicine and Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA; School of Medical Diagnostic and Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA
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6
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Marik PE, Rivera R, Hooper MH, Khangoora V, Catravas J. Response. Chest 2019; 152:677. [PMID: 28889882 DOI: 10.1016/j.chest.2017.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Racquel Rivera
- Department of Pharmacy, Sentara Norfolk General Hospital; and the School of Medical Diagnostic and Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - John Catravas
- Departments of Medicine and Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA
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7
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Hager DN, Hooper MH, Bernard GR, Busse LW, Ely EW, Fowler AA, Gaieski DF, Hall A, Hinson JS, Jackson JC, Kelen GD, Levine M, Lindsell CJ, Malone RE, McGlothlin A, Rothman RE, Viele K, Wright DW, Sevransky JE, Martin GS. The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) Protocol: a prospective, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled, clinical trial. Trials 2019; 20:197. [PMID: 30953543 PMCID: PMC6451231 DOI: 10.1186/s13063-019-3254-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sepsis accounts for 30% to 50% of all in-hospital deaths in the United States. Other than antibiotics and source control, management strategies are largely supportive with fluid resuscitation and respiratory, renal, and circulatory support. Intravenous vitamin C in conjunction with thiamine and hydrocortisone has recently been suggested to improve outcomes in patients with sepsis in a single-center before-and-after study. However, before this therapeutic strategy is adopted, a rigorous assessment of its efficacy is needed. METHODS The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) trial is a prospective, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled trial. It will enroll patients with sepsis causing respiratory or circulatory compromise or both. Patients will be randomly assigned (1:1) to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 h or matching placebos until a total of 16 administrations have been completed or intensive care unit discharge occurs (whichever is first). Patients randomly assigned to the comparator group are permitted to receive open-label stress-dose steroids at the discretion of the treating clinical team. The primary outcome is consecutive days free of ventilator and vasopressor support (VVFDs) in the 30 days following randomization. The key secondary outcome is mortality at 30 days. Sample size will be determined adaptively by using interim analyses with pre-stated stopping rules to allow the early recognition of a large mortality benefit if one exists and to refocus on the more sensitive outcome of VVFDs if an early large mortality benefit is not observed. DISCUSSION VICTAS is a large, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled trial that will test the efficacy of vitamin C, thiamine, and hydrocortisone as a combined therapy in patients with respiratory or circulatory dysfunction (or both) resulting from sepsis. Because the components of this therapy are inexpensive and readily available and have very favorable risk profiles, demonstrated efficacy would have immediate implications for the management of sepsis worldwide. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03509350 . First registered on April 26, 2018, and last verified on December 20, 2018. Protocol version: 1.4, January 9, 2019.
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Affiliation(s)
- David N. Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Suite 9121, Baltimore, MD 21287 USA
| | - Michael H. Hooper
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, VA USA
| | - Gordon R. Bernard
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Laurence W. Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA USA
| | - E. Wesley Ely
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN USA
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN USA
| | - Alpha A. Fowler
- Division of Pulmonary Disease & Critical Care Medicine, Department of Internal Medicine, The VCU Johnson Center for Critical Care and Pulmonary Research, Virginia Commonwealth University School of Medicine, Richmond, VA USA
| | - David F. Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, GA USA
- Grady Memorial Hospital, Atlanta, GA USA
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | - James C. Jackson
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN USA
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN USA
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Gabor D. Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | - Mark Levine
- Molecular & Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD USA
| | | | - Richard E. Malone
- Investigational Drug Service, Vanderbilt University Medical Center, Nashville, TN USA
| | | | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | | | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA USA
- Grady Memorial Hospital, Atlanta, GA USA
| | - Jonathan E. Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA USA
| | - Greg S. Martin
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA USA
- Grady Memorial Hospital, Atlanta, GA USA
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8
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Hooper MH, Carr A, Marik PE. The adrenal-vitamin C axis: from fish to guinea pigs and primates. Crit Care 2019; 23:29. [PMID: 30691525 PMCID: PMC6348603 DOI: 10.1186/s13054-019-2332-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/22/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA
| | - Anitra Carr
- Department of Pathology, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA.
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Marik PE, Hooper MH. Adjuvant Vitamin C in critically ill patients undergoing renal replacement therapy: What's the right dose? Crit Care 2018; 22:320. [PMID: 30466487 PMCID: PMC6249758 DOI: 10.1186/s13054-018-2190-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/12/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, United States of America.
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, United States of America
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10
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Taeb AM, Sill JM, Derber CJ, Hooper MH. Nodular granulomatous Pneumocystis jiroveci pneumonia consequent to delayed immune reconstitution inflammatory syndrome. Int J STD AIDS 2018; 29:1451-1453. [PMID: 30114992 DOI: 10.1177/0956462418787603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although Pneumocystis jiroveci pneumonia (PCP) is a frequent manifestation of acquired immune deficiency syndrome (AIDS), the granulomatous form is uncommon. Here, we present an unusual case of granulomatous PCP consequent to immune reconstitution inflammatory syndrome (IRIS) after highly active antiretroviral therapy. A 36-year-old woman with human immunodeficiency virus (HIV) presented with cough and dyspnea that were attributed to typical PCP associated with AIDS. She was successfully treated with antibiotic, steroid, and antiretroviral therapies. After six months, however, she presented with consolidating lung lesions caused by bronchial obstruction from PCP granulomatous disease. Although antibiotics were ineffective, the effectiveness of steroid therapy suggested a diagnosis of granulomatous IRIS caused by persistent PCP antigens. Physicians should strongly suspect PCP in HIV-positive patients with nodular lung lesions and must remain aware that these lesions, if immune in origin, might not respond to antimicrobial therapy.
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Affiliation(s)
- Abdalsamih M Taeb
- 1 Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Joshua M Sill
- 1 Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Catherine J Derber
- 2 Division of Infectious Diseases, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Michael H Hooper
- 1 Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA.
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA
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Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest 2017; 151:1229-1238. [PMID: 27940189 DOI: 10.1016/j.chest.2016.11.036] [Citation(s) in RCA: 589] [Impact Index Per Article: 84.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 10/31/2016] [Accepted: 11/16/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The global burden of sepsis is estimated as 15 to 19 million cases annually, with a mortality rate approaching 60% in low-income countries. METHODS In this retrospective before-after clinical study, we compared the outcome and clinical course of consecutive septic patients treated with intravenous vitamin C, hydrocortisone, and thiamine during a 7-month period (treatment group) with a control group treated in our ICU during the preceding 7 months. The primary outcome was hospital survival. A propensity score was generated to adjust the primary outcome. RESULTS There were 47 patients in both treatment and control groups, with no significant differences in baseline characteristics between the two groups. The hospital mortality was 8.5% (4 of 47) in the treatment group compared with 40.4% (19 of 47) in the control group (P < .001). The propensity adjusted odds of mortality in the patients treated with the vitamin C protocol was 0.13 (95% CI, 0.04-0.48; P = .002). The Sepsis-Related Organ Failure Assessment score decreased in all patients in the treatment group, with none developing progressive organ failure. All patients in the treatment group were weaned off vasopressors, a mean of 18.3 ± 9.8 h after starting treatment with the vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4 h in the control group (P < .001). CONCLUSIONS Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, are effective in preventing progressive organ dysfunction, including acute kidney injury, and in reducing the mortality of patients with severe sepsis and septic shock. Additional studies are required to confirm these preliminary findings.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Racquel Rivera
- Department of Pharmacy, Sentara Norfolk General Hospital, Norfolk, VA
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - John Catravas
- School of Medical Diagnostic & Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA; Department of Medicine and Department of Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA
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Abstract
Sepsis is a clinical syndrome that results from the dysregulated inflammatory response to infection that leads to organ dysfunction. The resulting losses to society in terms of financial burden, morbidity, and mortality are enormous. We provide a review of sepsis, its underlying pathophysiology, and guidance for diagnosis and management of this common disease. Current established treatments include appropriate antimicrobial agents to target the underlying infection, optimization of intravascular volume to improve stroke volume, vasopressors to counteract vasoplegic shock, and high-quality supportive care. Appropriate implementation of established treatments combined with novel therapeutic approaches promises to continue to decrease the impact of this disease.
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Affiliation(s)
- Abdalsamih M Taeb
- 1 Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Michael H Hooper
- 1 Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Paul E Marik
- 1 Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Marik PE, Hooper MH. Normocaloric versus hypocaloric feeding on the outcomes of ICU patients: a systematic review and meta-analysis. Intensive Care Med 2015; 42:316-323. [PMID: 26556615 DOI: 10.1007/s00134-015-4131-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 10/29/2015] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Current clinical practice guidelines recommend providing ICU patients a daily caloric intake estimated to match 80-100 % of energy expenditure (normocaloric goals). However, recent clinical trials of intentional hypocaloric feeding question this approach. METHODS We performed a systematic review and meta-analysis to compare the outcomes of ICU patients randomized to intentional hypocaloric or normocaloric goals. We included randomized controlled trials that enrolled ICU patients and compared intentional hypocaloric with normocaloric nutritional goals. We included studies that evaluated both trophic feeding as well as permissive underfeeding. Data sources included MEDLINE, Cochrane Register of Controlled Trials and citation review of relevant primary and review articles. The outcomes of interest included hospital acquired infection, hospital mortality, ICU length of stay (LOS) and ventilator-free days (VFDs). RESULTS Six studies which enrolled 2517 patients met our inclusion criteria. The mean age and body mass index (BMI) across the studies were 53 ± 5 years and 29.1 ± 1.5 kg/m(2), respectively. Two studies compared normocaloric feeding (77% of goal) with trophic feeding (20% of goal), while four studies compared normocaloric feeding (72% of goal) with permissive underfeeding (49% of goal). Overall, there was no significant difference in the risk of infectious complications (OR 1.03; 95% CI 0.84-1.27, I(2) = 16%), hospital mortality (OR 0.91; 95% CI 0.75-1.11, I(2) = 8%) or ICU LOS (mean difference 0.05 days; 95% CI 1.33-1.44 days; I(2) = 37%) between groups. VFDs were reported in three studies with no significant difference between the normocaloric and intentional hypocaloric groups (data not pooled). CONCLUSION This meta-analysis demonstrated no difference in the risk of acquired infections, hospital mortality, ICU length of stay or ventilator-free days between patients receiving intentional hypocaloric as compared to normocaloric nutritional goals.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA.
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA
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Hooper MH, Kelly UM, Marik PE. An overview of the diagnosis and management of Clostridium difficile infection. Hosp Pract (1995) 2012; 40:119-129. [PMID: 22406887 DOI: 10.3810/hp.2012.02.952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The diagnosis and treatment of Clostridium difficile infection are becoming increasingly complex with the introduction of novel diagnostic techniques and new pharmacologic and nonpharmacologic treatments. The integration of these new approaches with older, established methods is a challenge to individual clinicians and hospital systems. This article provides an overview of the current methods for the diagnosis and treatment of C difficile infection.
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Affiliation(s)
- Michael H Hooper
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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Hooper MH, Girard TD. Sedation and weaning from mechanical ventilation: linking spontaneous awakening trials and spontaneous breathing trials to improve patient outcomes. Anesthesiol Clin 2011; 29:651-61. [PMID: 22078914 DOI: 10.1016/j.anclin.2011.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The use of sedation has long been integrated into critical care. Because pain, discomfort, anxiety, and agitation are commonly experienced by critically ill patients, the use of medications to alleviate and control these symptoms will continue; however, data showing that prolonged use of sedating medications imparts harm to patients obligate physicians to use agents and methods of sedation that minimize these negative side effects. Numerous observational studies and clinical trials have proven that decisions in sedation management play a crucial role in determining outcomes for mechanically ventilated ICU patients, and recent evidence supports the use of protocols that streamline efforts to discontinue sedation and mechanical ventilation in a safe and parallel fashion. Regardless of choice of sedating agent, and even when patient-targeted sedation protocols are used to minimize oversedation, the use of spontaneous awakening trials dramatically improves patient outcomes for critically ill patients. Intensive care physicians must continue to study the delivery of sedation in efforts to maximize patient comfort while minimizing patient harm.
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Affiliation(s)
- Michael H Hooper
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Vanderbilt University School of Medicine, 6th Floor MCE, #6100, Nashville, TN 37232-8300, USA.
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Hooper MH, Bernard GR. Pharmacogenetic treatment of acute respiratory distress syndrome. Minerva Anestesiol 2011; 77:624-636. [PMID: 21617626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) occur due to systemic inflammatory disorders or direct injury to the lung. The occurrence of ALI/ARDS is sporadic and is not reliably predicted by the type or severity of injury. A combination of patient characteristics and mechanism of injury are responsible for the sporadic nature of ALI/ARDS and its observed phenotypic variability. Research on the pathophysiology and genetics of ALI/ARDS continues to advance, revealing critical molecular pathways in disease development and specific genetic factors that alter the expression of disease. Despite these advances, pharmacologic therapies have yet to be developed for the prevention or treatment of disease. We anticipate that continued improvement of our understanding of the genetic and pathophysiologic mechanisms underlying ALI/ARDS combined with future clinical trials will allow pharmacogenetic therapies for ALI/ARDS to be developed.
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Affiliation(s)
- M H Hooper
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
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Hooper MH, Girard TD. Sedation and weaning from mechanical ventilation: linking spontaneous awakening trials and spontaneous breathing trials to improve patient outcomes. Crit Care Clin 2009; 25:515-25, viii. [PMID: 19576527 DOI: 10.1016/j.ccc.2009.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Liberation from mechanical ventilation is a vital treatment goal in the management of critically ill patients. The duration of mechanical ventilation is affected by strategies for ventilator weaning and sedation. The authors review literature on weaning from mechanical ventilation and delivery of sedation in critically ill patients, including current guidelines recommending the use of spontaneous breathing trials and spontaneous awakening trials. Implementation of these strategies in a wake-up-and-breathe protocol has demonstrated benefit over the use of spontaneous breathing trials alone.
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Affiliation(s)
- Michael H Hooper
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN 37232-8300, USA.
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