Effect of Intravenous Vitamin C, Thiamine, and Hydrocortisone (The Metabolic Resuscitation Protocol) on Early Weaning from Vasopressors in Patients with Septic Shock. A Descriptive Case Series Study

Abstract

Objectives: The aim of this study was to assess the efficacy of intravenous vitamin C, hydrocortisone, and thiamine in early weaning (within 48 hours) from vasopressor support in patients with septic shock. We also aimed to assess mortality and intensive care unit (ICU) stay. Study Design: We conducted a descriptive case series study of 50 patients with septic shock who were admitted in the ICU of the Combined Military Hospital Rawalpindi in Pakistan from August 2017 until April 2018. Materials and Methods: The study included men and women (16 to 80 years of age) who were admitted to the ICU with septic shock. Data were analysed using the IBM Statistical Package for Social Sciences (SPSS), version 18.0 (IBM Corp., Armonk, NY, USA). Inferential analysis was done with the help of simple and multivariate binary logistic regression that generated unadjusted and adjusted odds ratios (OR), respectively. Results: Of the 50 patients, 56% (N = 28) were male with a mean age of the respondents being 46.7 ± 18.4. Eighty-four percent were successfully weaned off vasopressors within 48 hours. Median days in the ICU were reported as 8.3 (interquartile range (IQR) = 5). Primary bacteremia (34%) was the most reported cause of ICU admission. The most common vasopressor was norepinephrine and its mean dose was 21.6 ± 10.7 microgram/min. The ICU mortality was observed at 52% (N = 26). Unadjusted OR showed a dose of norepinephrine, Sequential Organ Failure Assessment (SOFA) score, plasma procalcitonin, and plasma lactate to be significant predictors (p-value < 0.05), while the adjusted odds ratio (AOR) showed only a dose of norepinephrine to be a statistically significant predictor (AOR = 0.804, 95% CI = 0.674-0.960; p-value = 0.016). Conclusion: The administration of intravenous vitamin C, hydrocortisone, and thiamine to patients with septic shock was successful in early weaning from vasopressors. There was also a reduction in procalcitonin and lactate levels, as well as the SOFA score. Further trials are needed to determine whether the metabolic resuscitation protocol can become part of the treatment for septic shock.

Mortality in septic patients treated with vitamin C: a systematic meta-analysis

“…After duplicates were removed (n = 214), 30 articles were identified as potentially appropriate. Following full-text review, a total of 13 studies were excluded due to unpublished data (n = 2) [33,34], deviating study interventions (n = 6) [35][36][37][38][39][40], missing outcome parameters (n = 1) [41], missing control group, (n = 2) [42,43], and deviating study populations (n = 2) [44,45]. The included 17 trials summarized randomized and non-randomized, blinded and unblinded, prospective and retrospective, and single-and multi-center studies (Table 1 and Additional file 1: Table S1).…”

“…1. The same investigators screened the search results according to the title and abstract, reviewed the full-text articles, considered the study for inclusion, and extracted appropriate data from the publications [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][33][34][35][36][37][38][39][40][41][42][43][44][45].…”

Adjuvant therapies and sepsis from multidrug resistant bacteria: a narrative review

“…None of the patients in the treatment group developed new organ failure (as reflected by an increase in their SOFA score) requiring an escalation of therapy. Also Masood et al [37] (2019) adopted a protocol study similar to the previous one. The authors develop a crosssectional study in order to analyze the effect vitamin C, hydrocortisone, and thiamine in patients with septic shock.…”

Is the Sympathetic System Detrimental in the Setting of Septic Shock, with Antihypertensive Agents as a Counterintuitive Approach? A Clinical Proposition

“…Finally, the lack of responsiveness of vascular smooth muscle to pressor drugs in sepsis is proven [ 61 , 74 , 75 , 76 ]. To address this peripheral component, steroids [ 77 ], methylene blue [ 78 , 79 ], vitamin C [ 80 , 81 ], B12, B1 (thiamine), or nitroglycerin [ 82 ] were investigated (“metabolic resuscitation”), but recent trials are non-conclusive [ 83 , 84 , 85 , 86 , 87 ].…”

“…Nevertheless, how can this putative vicious circle be broken if improved CO and improved mean BP are not sufficient? When patients are heading toward refractory septic shock and high NA requirements, the literature suggests using (a) angiotensin [ 71 , 73 ] and/or vasopressin [ 61 ]; (b) peripheral tools (“metabolic resuscitation”: steroids, methylene blue [ 78 , 79 ], vitamin C [ 80 , 81 ], B12, B1 (thiamine), nitroglycerin [ 82 ], prostacyclin); and/or (c) antihypertensive agents: alpha-2 agonists, beta-blockers or a converting enzyme inhibitor [ 70 ]. The need to normalize the sympathetic hyperactivity toward baseline and improve circulatory status and outcome may extend to normalize angiotensin and vasopressin systems as well, bearing in mind their close coordination.…”