June - 2017
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Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study
CHEST, 2017, 151(6):1229-1238
We don't usually include retrospective before and after studies in JC, but this analysis of a three pronged novel sepsis treatment - vitamin C, thiamine, and “moderate-dose” hydrocortisone - has gained a lot of attention, and generated a lot of debate about the intersection of social media and science.
In this retrospective before and after study;
There are obvious limitations;
However there has been a lot of interest in the result, and their are biological mechanisms that could explain an effect. Given this, a sensible course could be to use this as hypothesis generating, and design observational then if warranted interventional studies to investigate this novel treatment regime.
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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