An Orange a Day to Keep Sepsis at Bay: Hydrocortisone + Vitamin C + Thiamine as Adjunct

Treatment of Septic Shock

Kyllie Shae Ryan-Hummel, PharmD PGY2 Critical Care Resident University Health System

The University of Texas at Austin College of Pharmacy UT Health San Antonio

September 5, 2017 and September 8, 2017

At the end of this session, the learner will be able to: 1. Summarize current guideline-indicated treatment strategies for septic shock2. Describe potential adjunct therapies, including hydrocortisone, thiamine, and ascorbic acid for patients with

septic shock3. Evaluate the effect of triple therapy with hydrocortisone, thiamine, and ascorbic acid on clinical outcomes in

septic shock

RYAN-HUMMEL 2

An Orange a Day to Keep Sepsis at Bay:

Hydrocortisone + Vitamin C + Thiamine as Adjunct Treatment of Septic Shock

Kyllie Shae Ryan-Hummel, PharmD PGY2 Critical Care Resident

September 5, 2017 at 2:00 and September 8, 2017 at 3:00 University Health System and McDermott Building

Learning Objectives: At the completion of this activity, the participant will be able to: 1. Summarize current guideline-indicated treatment strategies for septic shock 2. Describe potential adjunct therapies, including hydrocortisone, thiamine, and ascorbic acid, for patients with septic

shock 3. Evaluate the effect of triple therapy with hydrocortisone, thiamine, and ascorbic acid on clinical outcomes in septic

shock Assessment Questions: T F—Thiamine is added to the triple therapy because all patients have vitamin B deficiency. Multiple Choice—Current guidelines state all the following agents may be used in septic shock treatment EXCEPT:

1. Norepinephrine 2. Empiric antibiotics 3. Fluid resuscitation with crystalloids 4. Hydrocortisone 5. Dexamethasone

T F— A 2016 clinical trial proposed a novel adjunctive treatment using hydrocortisone, vitamin C, and thiamine for septic

shock patients which improved mortality but caused renal toxicity. ***To obtain CE credit for attending this program please sign in. Attendees will be emailed a link to an electronic CE Evaluation Form. CE credit will be awarded upon completion of the electronic form. If you do not receive an email within 72 hours, please contact the CE Administrator at ana.franco-martinez@uhs-sa.com ***

Speaker Disclosure: Kyllie Shae Ryan-Hummel has indicated she has no relevant financial relationships to disclose relative to the content of her presentation.

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Sepsis

I. Definitions1-5 a. 1992 American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) definitions1-3

i. Systemic Inflammatory Response Syndrome (SIRS): combination of findings resulting from systemic activation of innate immune response (Appendix A)1,2

ii. Sepsis: SIRS plus presumed or proven infection iii. Severe sepsis: sepsis associated with hypoperfusion, hypotension, or organ dysfunction iv. Septic shock: sepsis with arterial hypotension after appropriate fluid resuscitation

b. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) definitions4 i. Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection

1. Organ dysfunction: change in Sequential Organ Failure Assessment (SOFA) score by ³2 points (Appendix B)4,5

a. Validated scale for grading severity of organ dysfunction in critically ill b. Assesses six organ systems and scores them on degree of severity (0-4; 4 being the worst) c. Baseline score zero unless preexisting organ dysfunction d. Higher scores associated with increased mortality

i. Score ³2 and suspected infection have a risk of mortality >10% ii. Score >11 points has predictive mortality of 95%

2. Quick SOFA (qSOFA) score (Appendix C)4,5 a. Used to identify patients with suspected sepsis and high likelihood of prolonged ICU stay or

mortality b. Sepsis-3 task force suggests that positive qSOFA should prompt clinicians to look for organ

dysfunction/infection and initiate or escalate care c. Utilized in out of hospital settings, general wards, and emergency departments

ii. Septic shock: subset of sepsis with profound underlying circulatory and cellular metabolic abnormalities; associated with substantially increased mortality4,5

1. Adequate fluid resuscitation 2. Persistent hypotension requiring vasopressors to keep mean arterial pressure (MAP) ³65 mmHg 3. Serum lactate >2 mmol/L (18 mg/dL)

II. Epidemiology6,7 a. Associated with high morbidity and mortality even with optimal therapy7

i. Sepsis-related mortality is ³10% ii. Septic shock-related mortality is ³40%

b. Accounted for $23.7 billion in healthcare costs in 20136 c. Incidence of “severe sepsis” is 300/100,000 patients in United States7 d. Pneumonia is most common infection leading to sepsis6

III. Risk factors associated with sepsis8,9

Table 1. Sepsis risk factors8,9

Non-modifiable Modifiable African American Alcohol dependence/alcoholism

Male Smoking

³ 65 years old Lack of up-to-date vaccinations

Cirrhosis Immunosuppression

Invasive lines

IV. Pathophysiology and clinical manifestations8

a. Cellular and molecular level changes8 i. Infection triggers proinflammatory signaling via the innate immune system (macrophages, monocytes,

granulocytes, natural killer cells, dendritic cells) 1. Activation of innate immune cells stimulates transcription of pro-inflammatory cytokines and type I

interferons (tumor necrosis factor-a [TNF-a], interleukins [IL-1, IL-6]) ii. Cellular damage from overproduction of inflammatory markers

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1. Reactive oxygen species (ROS) (e.g., nitric oxide, hydroxyl radicals) a. Damage essential molecules b. Disrupt normal actions of cellular proteins, lipids, DNA, and mitochondria

2. Complement activation a. Increase ROS formation b. Enzyme release from granulocytes c. Increased endothelial permeability d. Tissue factor expression e. Adrenal medullary cell apoptosis

3. Immunothrombosis leading to disseminated intravascular coagulopathy (DIC) a. Impaired microvascular function and organ injury b. Increased activation of inflammatory pathways

iii. Metabolic dysfunction8 1. Cell death mainly confined to lymphatic tissues 2. Mitochondrial dysfunction results primarily from high levels of ROS

a. Adenosine triphosphate (ATP) levels drop causing viable cells to enter “hibernation” state i. Decreased cellular function which promotes widespread organ dysfunction

ii. Myocardial depression iii. Hepatic dysfunction iv. Acute kidney injury v. Acute lung injury

vi. Encephalopathy vii. Decreased function of gastrointestinal tract

3. Muscle catabolism b. Tissue and organ dysfunction8

i. Cardiovascular 1. Systemic inflammation causes

a. Decreased systemic vascular resistance i. Hypotension results in poor perfusion of tissues and organs

ii. Switch to anaerobic metabolism leads to increased lactate levels b. After appropriate volume resuscitation, normal or increased cardiac output despite presence

of acute ventricular dysfunction ii. Endothelial dysregulation alters

1. Vasomotor tone 2. Coagulation system 3. Cell and nutrient movement 4. Inflammatory and anti-inflammatory signaling

iii. Widespread tissue edema 1. Endothelial vasodilation 2. Loss of barrier function 3. Increased leukocyte adhesion 4. Shift to procoagulant state

iv. Microcirculatory changes 1. Obstruction of microvessel lumens due to microthrombi, leukocyte, and erythrocyte plugs 2. Impaired response to local stimulation 3. Tissue factor expression 4. Fibrin deposition 5. Impaired anticoagulant mechanisms leading to DIC

v. Renal injury 1. Result of hypoperfusion 2. Decreased urine output and increased serum creatinine levels 3. Often requires renal-replacement therapy

V. Management and treatment of septic shock3-5,10 a. Initial therapy

i. Fluid resuscitation

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1. Initial bolus of 30 mL/kg of IV crystalloid administered within first three hours of recognition 2. Goals of therapy

a. Target MAP ≥65 mmHg b. Normalize lactate levels

ii. Vasopressors (Appendix D) 1. First line: norepinephrine 2. Second line: vasopressin 3. Initiation and titration of vasopressors should be individualized based on patient response

b. Early initiation of broad spectrum antibiotics i. Broad spectrum IV antibiotic therapy within one hour of recognition

1. Each hour delay in treatment increases mortality 7.6%11 ii. Obtain blood cultures prior to broad spectrum antibiotics

1. Do not delay initiation of antibiotics to obtain blood cultures c. Procalcitonin12,13

i. Biomarker used to identify presence of infection 1. Should not be used to identify/diagnose sepsis 2. Higher value is associated with increased mortality 3. Can be helpful for de-escalation of antimicrobial therapy

ii. Cannot reliably or accurately differentiate between SIRS and sepsis in critically ill patients 1. Sensitivity 77% 2. Specificity 39%

Hydrocortisone

I. Mechanism and pathophysiology14 a. High doses suppress production of excessive inflammatory signals

i. Decrease damage associated with high inflammatory states b. Low dose steroids (<300 mg/day)

i. Increase responsiveness of vascular smooth muscle to exogenous and endogenous vasopressors ii. May improve balance of innate immune system

iii. Replenish anti-inflammatory effects (cytokine suppression) iv. Have minimal immunosuppressive effects v. May reverse endothelial activation and sepsis-related clotting disorders

II. Critical illness related corticosteroid insufficiency (CIRCI)15 a. Inadequate cellular corticosteroid activity in relation to the severity of illness15

i. Insufficient down-regulation of proinflammatory transcription factors ii. Persistent elevations of proinflammatory mediators

b. Pathophysiology15 i. Reversible decrease in adrenal steroid production or tissue resistance to adrenal steroids

ii. Adrenal insufficiency can occur at any level on hypothalamic-pituitary-adrenal axis iii. Effects on metabolic, immune, vascular, and organ functions iv. Diagnosis15-17

1. Objective diagnosis a. Delta cortisol <9 mcg/dL after administration of 250 mcg IV cosyntropin b. Random total cortisol <10 mcg/dL

2. Clinical application15 a. Cosyntropin stimulation test should not be used to identify septic shock patients b. Critically ill patients have a disconnect between total cortisol and free cortisol levels c. May not be representative of the amount of useable free cortisol

c. Treatment15 i. Clinical criteria dictates use of glucocorticoids in septic patients

1. Consider hydrocortisone in septic shock who have poor response to fluid resuscitation and vasopressor therapy

ii. Dosing strategy: IV hydrocortisone 200 mg/day divided into four daily doses (50 mg every 6 hours)

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III. Rationale for use in septic shock a. Decreased mortality b. Reversal of CIRCI c. No immunosuppression seen with low-dose d. Vasopressor duration decreased

IV. Efficacy and safety of hydrocortisone in septic shock patients18-20

Annane 200218 CORTICUS 200819 HYPRESS 201620

Design Multicenter, placebo-controlled, double-blind, randomized

Multicenter, placebo-controlled, double-blind, randomized

Multicenter, placebo-controlled, double-blind, randomized

Population Septic shock (n=299) Septic shock (n=499) Severe sepsis—not shock (n=353)

28-day mortality 55% hydrocortisone 61% placebo

34.3% hydrocortisone 31.5% placebo

8.8% hydrocortisone 8.2% placebo

Baseline SAPS II 60 vs 57 SAPS II SOFA

49.5 vs 48.6 10.6 vs 10.6

SAPS II SOFA APACHE II

56.1 vs 52.2 6.4 vs 6.2 19.5 vs 18.5

Timing 3-8 hours <72 hours n/a

Vasopressor ⇓ Duration ⇓ Duration n/a

Mortality ⇓ Mortality in non-responders No difference & NOT powered No difference & NOT powered

Shock reversal ⇓ Time to reversal ⇓ Time to reversal No septic shock prevention

Katsenos CS, Antonopoulou AN, Apostolidou EN, et al. Early administration of hydrocortisone replacement after the advent of septic shock: impact on survival and immune response. Crit Care Med 2014;42:1651-7.21

Objectives • Identify impact of early hydrocortisone initiation on the clinical course of septic shock and cytokine release Design & Methods

• Non-randomized, prospective, longitudinal study • Septic shock patients, admitted to ICU or internal medicine departments over a two-year period

Patient Population

Inclusion Exclusion • ³18 years old • Septic shock defined as adequate fluid resuscitation,

SBP <90 mmHg and need for vasopressors • NE >0.5 mcg/kg/min • Hydrocortisone 50 mg IV q6h for 7 days • Antimicrobials within 48 hours of hydrocortisone

• Vasopressor other than NE • Immunosuppression (e.g., HIV, neutropenia, corticosteroid use) • Severe immunosuppression

o Solid tumor or hematologic malignancy o Antineoplastic chemotherapy

• Palliative treatment only or withdrawal of therapy decision

Study Groups • Early initiation of hydrocortisone: less than nine hours post-vasopressor initiation (n=46) • Late initiation of hydrocortisone: more than nine hours post-vasopressor initiation (n=124) • 34 patients were sampled for peripheral blood mononuclear cells and cytokine stimulation 24-hours post hydrocortisone initiation

Outcomes

• Primary endpoint o Effect of delaying hydrocortisone therapy after initiating norepinephrine on final clinical outcomes

• Secondary endpoints o Effect of delaying hydrocortisone therapy after initiating norepinephrine on cytokine stimulation of circulating monocytes

Statistics

• Baseline characteristics compared using Student T test for continuous variables and chi-square for nominal variables • OR and 95% CI calculated using Mantel-Haenzel’s statistics • Kaplan-Meier analysis assessed survival and time on vasopressors; compared using log-rank tests • Univariate analysis completed to analyze effect of nominal variables on outcome

o Significant variables entered with APACHE II score as a marker for disease severity using forward stepwise cox and logistic regression analyses; HR and 95% CI calculated

• TNF-α produced by PBMCs and monocytes compared between patients in different quartiles using analysis of variance • ROC curve analysis performed to confirm early vs late initiation was correct selection to make • Significance was determined by p <0.05

Baseline Characteristics

(n=170)

Early initiation (n=46) Late initiation (n=124) p-value Male, n (%) 26 (56.5) 84 (67.7) 0.207 Age in years, mean ± SD 65.2 ± 19.7 62.8 ± 16.9 0.432 APACHE II score, mean ± SD 26.3 ± 9.9 23.9 ± 11.5 0.229 SOFA score, mean ± SD 11.5 ± 3.8 10.7 ± 3.6 0.307 Infection, n (%) Ventilator-associated pneumonia Primary bacteremia

14 (30.4) 13 (28.3)

63(50.8) 33 (26.6)

0.144

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V. Current indications10

a. Low dose hydrocortisone reverses steroid deficiency due to relative adrenal insufficiency caused by CIRCI b. Guidelines state hydrocortisone can be considered in patients with septic shock who require vasopressor therapy

for at least one hour Vitamin C

I. Mechanism and pathophysiology a. Electron reducing agent and antioxidant22,23

i. Scavenges ROS ii. Inhibits NADPH oxidase and superoxide synthesis in microvascular endothelial cells

b. Infection triggers a systemic inflammatory response leading to vitamin C depletion23 c. Vitamin C protects arteriolar responsiveness and capillary blood flow

i. Inhibits oxidative stress ii. Reduces ROS; decreases further damage to endothelium and organs

iii. Modulates intracellular signaling pathways iv. Maintains homeostatic nitric oxide levels

d. Accumulates in neutrophils, monocytes, lymphocytes, and platelets which suggests it may be a vital component of appropriately functioning immune cells22

II. Rationale for use in septic shock22,24-27 a. Essential water-soluble exogenous micronutrient b. Highest concentrations in brain and adrenal glands, where catecholamines are synthesized c. Low vitamin C levels (hyposcorbia) often seen in septic and critically ill patients

i. Increased vitamin C requirement leads to total body depletion 1. Increased ROS causes oxidation 2. Decreased transport into cells via vitamin C-specific transporters (SVCT1 and SVCT2) 3. Suboptimal levels associated with higher rates of organ dysfunction and mortality

ii. Administration of IV vitamin C 1. Attenuates development and effects of multiple organ dysfunction syndrome (MODS)22

Intraabdominal infections Community-acquired pneumonia Urosepsis Other

5 (10.9) 4 (8.7) 6 (13.0) 4 (8.7)

11 (8.9) 8 (6.5) 5 (4.0) 4 (3.2)

Pathogen, n (%) Klebsiella pneumoniae Acinetobacter baumannii Pseudomonas aeruginosa Other

11 (23.9) 4 (8.7)

5 (10.91) 9 (19.6)

25 (20.2) 32 (25.8) 15 (12.1) 13 (10.5)

0.673 0.019 0.532 0.128

Appropriateness of antimicrobials, n (%) 27 (93.1) 68 (80.0) 0.149

Results (n=170)

Primary outcomes Early initiation (n=46) Late initiation (n=124) p-value OR Survival 52.2% 30.6% 0.012 0.40 (95% CI 0.20-0.81) • ROC analysis showed early administration had better overall survival (AUC=0.613; p=0.014)

o Kaplan-Meier survival analysis had better overall survival (p=0.018) Secondary outcomes

• Vasopressor discontinuation (early vs late): 4 vs 15 days (p<0.0001) • Early initiation (n=46) had lower TNF-a production

Conclusions • Early initiation of hydrocortisone in septic shock patients is associated with improved survival • TNF-a production by PBMCs and monocytes was reduced in patients receiving earlier hydrocortisone administration

Critique

Strengths Limitations • None of the patients received chronic corticosteroids • Only included patients receiving NE >0.5 mcg/kg/min • Vasopressin was not administered • Hydrocortisone 50 mg q6h

• Non-randomized design and lack of untreated comparator arm • Not all patients initiated on appropriate antibiotics • Early group trending towards more severely ill • Duration of days until vasopressor discontinuation vastly different

APACHE II=acute physiology and chronic health evaluation II score; AUC=area under the curve; BP=blood pressure; CHF=chronic heart failure; CI=confidence interval; COPD=chronic obstructive pulmonary disease; Corticosteroids=prednisone >1 mg/kg for past month; CRD=chronic renal disease; CVP=central venous pressure; DM=diabetes mellitus; h=hours; HIV=human immunodeficiency virus; HR=hazard ratio; ICU=intensive care unit; NE=norepinephrine; Neutropenia=WBC <1,000 neutrophils/mm3; OR=odds ratio; PBMC=peripheral blood mononuclear cells; q=every; ROC=receiver operator characteristics; SOFA=sequential organ failure assessment score; TNF-a=tumor necrosis factor alpha; WBC=white blood cell

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2. Reverses arteriolar hypo-responsiveness to endogenous vasoconstrictors (angiotensin, vasopressin, norepinephrine)25

3. Acts as a cofactor for copper-containing enzymes and increases formation of vitamin-C dependent vasopressors24,26

a. Synthesis of norepinephrine i. Enzyme uses oxygen to add a hydroxyl group to dopamine (Figure 1)

ii. Dopamine b-hydroxylase

Figure 1. Biosynthesis of norepinephrine

[AA=vitamin C]

b. Synthesis of vasopressin i. Enzyme converts glycine-extended peptide into intermediate products to be broken

down into active hormone and glyoxylate (Figure 2) ii. Peptidylglycine a-amidating monooxygenase (PAM)

Figure 2. Biosynthesis of vasopressin

[AA=vitamin C]

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4. Successful administration without nephrotoxicity a. IV doses exceeding recommended dietary allowances of vitamin C have been given without

adverse renal toxicities b. Studies commonly utilize 50-200 mg/kg/day which were not associated with renal toxicity or

adverse effects III. Rationale for vitamin C

a. Essential micronutrient that is depleted in septic shock b. Increase arteriolar response to endogenous vasoconstrictors c. Cofactor for synthesis of norepinephrine & vasopressin d. Improved outcomes in septic shock patients e. Safety & efficacy have been described in septic shock patients f. Early repletion through supra-physiologic doses necessary

IV. Efficacy and safety of vitamin C in septic shock patients28-30

Long 200328 Zabet 201629 Baharara 201630

Design Pharmacokinetic study Multicenter, placebo-controlled, double-blind, randomized

Case report

Population Critically ill; no renal failure (n=14) Septic shock (n=28) Sepsis-associated ARDS (n=1)

28-day mortality n/a 14.28% vs 64.28% n/a

Intervention IV vitamin C 300 mg (2 days) IV vitamin C 1000 mg (2 days) IV vitamin C 3000 mg (2 days)

IV vitamin C 25 mg/kg q6h x 72h IV vitamin C 50 mg/kg q6h On day 4 on two separate admissions

Baseline Injury severity score: 26±3 APACHE II SOFA

19.07 vs 23 11.78 vs 12.35

n/a

Outcomes Achieved normal plasma vitamin C levels on days 5, 6

⇓ Norepinephrine doses ⇓ duration of norepinephrine ⇓ mortality

Improved chest x-ray and subsequent extubation

Fowler AA, Syed AA, Knowlson S, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med 2014;12:32.31

Objective • Determine safety of IV ascorbic acid in patients with severe sepsis • Determine if ascorbic acid infusions impact organ failure measured by biomarkers

Design & Methods • Randomized, double-blind, placebo-controlled, phase I trial • Screened and enrolled upon admission to the medical ICU at VCU Medical Center

Patient Population

Inclusion Exclusion • Severe sepsis within 48 hours of ICU admission:

o SIRS o Suspected or proven infection o Sepsis-induced organ dysfunction

• Not meeting inclusion criteria

Intervention

• Treatment groups o Placebo (n=8) o Low-dose ascorbic acid (Lo-AscA): 50 mg/kg/day ascorbic acid (n=8) o High-dose ascorbic acid (Hi-AscA): 200 mg/kg/day ascorbic acid (n=8)

• Study drug initiated within 2-4 hours of informed consent and randomization • Ascorbic acid divided in 4 equal doses administered in 50 mL D5W over 30 minutes q6h for 4 days

Outcomes

• Primary endpoint o Assess ascorbic acid safety and tolerability by monitoring severity and frequency of treatment related adverse effects

§ Arterial hypotension, tachycardia, hypernatremia, nausea, vomiting • Secondary endpoints

o Vasopressor days o Ventilator-free days o ICU LOS o 28-day mortality

Statistics

• Results expressed as mean ± SE o Differences between groups analyzed using two-factor analysis of variance with Tukey’s studentized range test

• Summary data reported as mean ± SEM • Statistical significance reported as p-value <0.05 • SOFA scores based on the evolution of the delta daily SOFA score compared with day 0 over the 4 study days through comparison of

regression coefficients using Student’s T test

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V. Current indications

a. No mention in guidelines

Thiamine

I. Mechanism and pathophysiology32,33 a. Water-soluble vitamin essential to cellular metabolism, existing in the human body in various forms32 b. Essential for converting glucose into energy32

i. Depletion of thiamine decreases activity of pyruvate dehydrogenase (Figure 3) 1. Decreased decarboxylation of pyruvate into acetyl coenzyme A 2. Decreased initiation of Krebs cycle

Figure 3. Metabolic role of thiamine

Baseline Characteristics

(n=24)

Placebo (n=8) Lo-AscA (n=8) Hi-AscA (n=8) p-value Male, n (%) 4 (50) 5 (62.5) 4 (50) ns Age, years 54-68 30-70 49-92 ns APACHE II score, mean (range) 20.4 (15-29) 20.4 (12-23) 24.0 (12-33) ns SOFA score, mean ± SE 13.3 ± 2.9 10.1 ± 2.0 10.8 ± 4.4 ns Plasma vitamin C in µM, mean (range) 20.2 (11-45) 16.7 (14-28) 17.0 (11-50) ns

Results (n=24)

Primary outcome safety of ascorbic acid • No patients were withdrawn due to adverse effects • Infusion was temporarily halted in one patient due to ventricular arrhythmia

Secondary outcomes Placebo (n=8) Lo-AscA (n=8) Hi-AscA (n=8) p-value Day 4 plasma vitamin C in µM, mean (range) 15.6 (7-27) 331 (110-806) 3082 (1592-5722) *** Vasopressor days, mean (range) 3.9 (1-10) 2.1 (1-6) 3.6 (2-8) ns Ventilator free days, mean (range) 7.6 (0-23) 8.4 (0-22) 4.8 (0-19) ns ICU LOS, mean (range) 11.0 (2-25) 8.1 (1-19) 9.1 (2-25) ns 28-day mortality, % 62.5 38.1 50.6 ns Plasma vitamin C levels within 12h • Lo-AscA vs placebo p<0.005 • Hi-AscA vs Lo-AscA p<0.005 Plasma vitamin C levels within 96h • Hi-AscA vs placebo p<0.0005 Impact of vitamin C infusion on organ failure • Vitamin C (both) vs placebo—descending SOFA scores over 4-day period • Hi-AscA vs placebo—exhibited faster declines in the regression slopes of delta daily total SOFA scores (−0.043 vs. 0.003; p<0.01) Impact of vitamin C infusion on biomarkers • AscA vs placebo—rapid reduction in CRP levels (p<0.05) • Hi-AscA vs non-Hi-AscA—significant decline in PCT levels, significantly lower than baseline by 48h (p<0.05)

Conclusions • IV vitamin C is tolerated and safe in septic shock patients • Use may positively impact biomarkers of endothelial injury, inflammation, and SOFA scores

Critique

Strengths Limitations • Established safety of high dose ascorbic acid • Compared against placebo • Patients had high SOFA scores (mean >10) • No adverse reactions at low or high doses • Vitamin C appears safe

• Small sample size • Did not address possible renal toxicity or status of renal function • No breakdown of SOFA scores • Need randomized control studies to identify efficacy

APACHE=acute physiology and chronic health evaluation II score; bpm=beats per minute; CRP=c-reactive protein; D5W=5% dextrose in water; HR=heart rate; ICU=intensive care unit; INR=international normalized ratio; IV=intravenous; LOS=length of stay; ns=not significant; OR=odds ratio; PCT=procalcitonin; q=every; SBP=systolic blood pressure; SE=standard error; SIRS=systemic inflammatory response syndrome; SEM=standard error of the mean; SOFA=sequential organ failure assessment score

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c. Daily repletion is necessary due to a short half-life and limited body stores32,33 d. Thiamine deficiency associated with a variety of clinical syndromes32,33

i. Cardiovascular disease ii. Beriberi syndrome

iii. Peripheral neuropathy iv. Wernicke-Korsakoff syndrome v. Refeeding syndrome

vi. Oxidative stress vii. Lactic acidosis

viii. Sepsis II. Rationale for use in septic shock32

a. Subclinical deficiency is highly prevalent in critically ill patients i. 20% of ICU admissions

ii. 21% of emergency department admissions b. Despite higher rates of morbidity and mortality seen with thiamine deficiency in critically ill, routine

supplementation is not used c. Unrecognized “relative thiamine deficiency syndrome” leads to lactic acid production d. Patients at highest risk for thiamine deficiency

i. Alcoholics ii. Chronic malnutrition or starvation

iii. Chemotherapy iv. Receiving diuretics v. Parenteral or enteral nutrition with inadequate supplementation

III. Efficacy and safety of thiamine in septic shock patients a. Donnino et al. studied prevalence of thiamine deficiency in critically ill septic patients and association with

lactic acidosis34 i. Prospective observational study in patients with evidence of tissue hypoperfusion requiring

vasopressor support (n=30) versus placebo (n=30) 1. Absolute thiamine deficiency upon admission to the ICU (n=3) 2. Thiamine deficiency developed within 72 hours (n=3)

ii. Found no correlation between lactic acidosis and thiamine deficiency (p=0.83) b. de Andrade et al. evaluated effects of thiamine deficiency on oxidative stress, cellular recruitment, and

inflammation in a murine sepsis model35 i. Postulated that thiamine deficiency

1. Further compounds oxidative stress 2. Associated with increased inflammation

ii. Findings 1. Thiamine deficiency occurred within 10 days in study mice fed thiamine deficient (TD) chow 2. TNF-α in peritoneal fluid significantly greater in cecal ligation and puncture (CLP) + thiamine

deficient (TD) chow group 3. Blood mononuclear cell counts increased in CLP+TD chow group (p<0.05) 4. Peritoneal bacterial colony forming units lower in the CLP+TD chow group

iii. Thiamine deficiency is associated with greater bacterial clearance, oxidative stress, and inflammatory response changes

Donnino MW, Andersen LW, Chase M, et al. Randomized, double-blind, placebo-controlled trial of thiamine as a metabolic resuscitator in septic shock: a pilot study. Crit Care Med 2016;44(2):360-7.36

Objective • Determine if IV thiamine reduces lactate levels in septic shock patients Design & Methods

• Randomized, double-blind, placebo-controlled, pilot study; DSMB evaluated for drug safety • Two tertiary care hospitals in Massachusetts between January 2010-October 2014; randomized in 1:1 ratio; stratified by participation site

Patient Population

Inclusion Exclusion • ³18 years old • Sepsis with the presence of ≥2 SIRS criteria

o Documented or suspected infection • Lactate >3 mmol/L • Hypotension: SBP <90 mmHg after ≥2L fluid bolus • Vasopressor dependence

• Liver injury/dysfunction (e.g., AST or ALT >240 units/L, cirrhosis) • Current thiamine supplementation • Clinical need for thiamine (e.g., alcohol abuse, beriberi) • Comfort measures only • Inability to provide consent • Alternative reason for elevated lactate levels

RYAN-HUMMEL 12

IV. Rational for thiamine a. Decreases lactic acid production in deficient patients b. Increases use of aerobic metabolism c. Decreases oxalic acid formation d. Improved outcomes in deficient patients e. High prevalence of thiamine deficiency in critically ill

Intervention • Placebo: 50 mL D5W q12h for 7 days or until hospital discharge • Thiamine: 200 mg in 50 mL D5W q12h for 7 days or until hospital discharge

Outcomes

• Primary endpoint o Lactate level at 24-hours post dose

• Secondary endpoints o Lactate levels at 6 and 12-hours post dose and the change at 24 hours o Lactate ≥4 mmol/L at 24 hours o Time to shock reversal (>24 hours off all vasopressors) o APACHE II score at 24 hours o SOFA score at 24 hours o ICU and hospital LOS o In-hospital mortality with classification of the mode of death

Statistics

• Study population summarized using descriptive statistics o Continuous variable presented as means (SD) or medians (1st quartile, 3rd quartile) depending on data normality

§ Wilcoxon rank sum tests and t-tests were used to compare continuous data between the groups o Categorical variable presented as frequencies or compared using Fisher’s exact tests

• All data based on modified intention to treat principle • Kaplan Meier curves created for survival and compared with the log- rank test • Patients censored at hospital discharge • All hypotheses were two sided with significance at p<0.05 • No adjustments made for multiple testing and all secondary outcomes considered exploratory

Baseline Characteristics

(n=88)

Thiamine (n=43) Placebo (n=45) Age in years, mean (SD) 70 (14) 65 (17) Female, n (%) 17 (40) 19 (42) Caucasian, n (%) 36 (84) 40 (89) APACHE II score, mean (SD) 25.7 (9.1) 26.5 (9.2) SOFA score, mean (SD) 10.1 (3.7) 10.2 (3.7)

Results (n=88)

Primary outcomes Thiamine (n=43) Placebo (n=45) p-value Lactate levels at 24 hours in mmol/L, median (quartiles) 2.5 (1.5-3.4) 2.6 (1.6-5.1) 0.40

Decrease in lactate levels from baseline to 24-hours was higher with significantly lower lactate concentrations in thiamine (p=0.048)***

***All pair-wise tests were performed without adjustment for multiple comparisons Secondary outcomes

Thiamine (n=43) Placebo (n=45) p-value

Lactate change at 24 hours, % (quartiles) 42 (17-51) 25 (-12-47) 0.16

Lactate ≥4 mmol/L at 24 hours, n (%) 9 (21) 17 (38) 0.10 Time to shock reversal (>24 hours off all vasopressors), % 74 71 0.81 APACHE II score at 24 hours, mean (SD) 23 (8) 26 (10) 0.15 SOFA score at 24 hours, mean (SD) 8.1 (3.5) 8.9 (5) 0.41 Time to ICU discharge in days, mean (SD) 8 (4-13) 7 (3-18) 0.70 Hospital LOS in days, mean (SD) 13 (8-20) 13 (7-24) 0.86 Inpatient mortality, % 42 44 1.00 Lactate levels at 6, 12, and 24-hours post-dose were non-significant Lactate at 24 hours in TD patients mmol/L, median (quartiles) 2.1 (1.4-2.5) 3.1 (1.9-8.3) 0.03 Time to death in favor of thiamine group log-rank test, p=0.047

Conclusions • Thiamine did not improve lactate levels or other secondary outcomes but did significantly improve lactate levels at 24 hours in patients with a baseline deficit

Critique

Strengths Limitations • High risk for Wernicke’s encephalopathy excluded • Included a critically ill population • Baseline characteristics similar between groups • Adverse effects were not mentioned

• Inclusion/exclusion criteria likely led to uneven cohorts • Small sample sizes; enrollment primarily from one site • Epinephrine patients were not excluded • Lack of adjustment for multiple comparisons • No information about how sepsis was treated • Kaplan Meier survival curve only reflects 28 of 88 total patients

ALT=alanine transaminase; APACHE=acute physiology and chronic health evaluation II score; AST= aspartate transaminase; bpm=beats per minute; D5W=5% dextrose in water; DSMB= data safety monitoring board; ED=emergency department; ICU=intensive care unit; INR=international normalized ratio; IV=intravenous; LOS=length of stay; n/a=not applicable; nr=not reported; ns=not significant; q=every; SBP=systolic blood pressure; SIRS=systemic inflammatory response syndrome; SOFA=sequential organ failure assessment score; TD=thiamine deficient

RYAN-HUMMEL 13

V. Current indications a. No mention in guidelines

Is triple therapy a successful adjunct for septic shock patients?

I. Triple therapy17,37-39 a. Combination therapy has additive effects that protect the vascular endothelium and reversed the

lipopolysaccharide (LPS)-induced barrier dysfunction compared to either agent used alone37 b. Vitamin C has been shown to reverse the oxidation of glucocorticoid receptors leading to increased

glucocorticoid activity38 c. Administration of glucocorticoids increases the sodium vitamin C transporter-2 expression which is essential for

vitamin C to be transported intracellularly39 d. Thiamine decreases the production of oxalic acid from the metabolism of vitamin C

Marik PE, Khangoora V, Rivera R, et al. Hydrocortisone, vitamin c, and thiamine for the treatment of severe sepsis and septic shock: a retrospective before-after study. CHEST 2017;151(6):1229-38.40

Objective • Determine if administration of vitamin C, hydrocortisone, and thiamine as adjunctive septic shock therapy is associated with improved survival rates

Design & Methods

• Retrospective, before-after study comparing outcomes of septic patients before and after implementation of new practice protocol • Consecutive septic patients treated with IV vitamin C, hydrocortisone, and thiamine (triple therapy) between January 2016 to July 2016

compared to control group treated between June 2015 to December 2015

Patient Population

Inclusion Exclusion • Severe sepsis or septic shock diagnosis • Procalcitonin >2 ng/mL

• <18 years old • Pregnant • DNR or DNR + limitations of care

Intervention

• Control group o Hydrocortisone (50 mg q6h) administered at the discretion of the attending physician

• Triple therapy group o Vitamin C: 1.5 g IV q6h for 4 days or until ICU discharge in 100 mL D5W or NS over 30-60 minutes o Hydrocortisone: 50 mg IV q6h for 7 days or until ICU discharge followed by a 3-day taper o Thiamine: 200 mg IV q12h for 4 days or until ICU discharge in 50 mL D5W or NS over 30 minutes

• Standard practice protocol utilized in both groups o Empiric initiation of broad spectrum antibiotics; deescalated as clinically relevant o Physiologically based vasopressor and fluid therapy

§ Norepinephrine 1st choice titrated to 20 mcg/min; 2nd vasopressin 0.04 units/min; 3rd phenylephrine or epinephrine o Lung-protective strategy while intubated o Limited sedation (preferred dexmedetomidine) o Enteral nutrition: whey-based formula and intermittent bolus within 24 hours post-ICU admission; allow permissive

hyperglycemia o Deep vein thrombosis prophylaxis with enoxaparin (heparin if CrCl <30 mL/min) and sequential compression devices o Routine stress ulcer prophylaxis is not practiced

Outcomes

• Primary endpoint o Hospital survival

• Secondary endpoints o Duration of vasopressor therapy o Renal replacement therapy requirement for acute kidney injury o ICU LOS o Change in serum procalcitonin o D SOFA score over 72 hours

Statistics

• Summary statistics used to describe clinical data: presented as means, SD, percentages and interquartile ranges • Analysis using Fisher’s exact test and Student’s t test (Mann-Whitney U test if non-normal distribution) • Statistical significance p<0.05 • Logistic discriminant analysis performed to determine independent predictors of survival • Propensity scores to control for likelihood to receive vitamin C protocol; help adjust potential baseline differences between groups • Binary logistic regression with propensity score adjustment performed to assess odds ratio for mortality by treatment group

Baseline Characteristics

(n=94)

Triple therapy (n=47) Control (n=47) p-value

Age in years, mean ± SD 58.3 ± 14.1 62.2 ± 14.3 ns Male, n (%) 27 (57) 23 (49) ns Vasopressors, n (%) 22 (46) 22 (46) ns Hydrocortisone treatment, n (%) 47 (100) 28 (59.6) ns Acute kidney injury, n (%) 31 (66) 30 (64) ns Renal replacement therapy, n (%) 3 (10) 11 (37) p=0.02

RYAN-HUMMEL 14

II. Rational for use in septic shock

a. Decreased mortality using triple therapy b. Decreased vasopressor requirements with triple therapy c. Improved organ function in septic shock patients d. Reversal of metabolic derangements

III. Current indications e. No mention in guidelines

Conclusions

I. Overall a. Treat septic shock per the Sepsis-3 guidelines and ensure that all normal therapies are provided for every patient b. Combination adjunct therapy using hydrocortisone + vitamin C + thiamine in septic shock patients is associated

with improved outcomes in septic shock patients when added to standard septic shock treatment i. Decreased time on vasopressor therapy

ii. Decreased mortality c. Adverse drug reaction not identified with single agent or in combination d. With all adjunct therapies, treatment has proven beneficial when therapies are not delayed and when they are

used in combination due to the synergism between the three agents II. Safety

a. Hydrocortisone has a long history of use in septic shock and is regarded safe at low doses (e.g. 50 mg q6h) b. Vitamin C has been administered safely in critically ill patients at doses of 12.5-50 mg/kg/dose q6h c. Thiamine is associated with improved outcomes when administered to deficient patients and is safe at levels of

200 mg q12h III. Efficacy

a. Hydrocortisone decreases mortality and time on vasopressor therapy b. Vitamin C decreases SOFA score and markers of inflammation c. Thiamine decreases mortality in patients who are thiamine deficient d. Triple cocktail decreases mortality, time on vasopressor therapy, SOFA score, and markers of inflammation

Lactate in mM, mean ± SD 2.7 ± 1.5 3.1 ± 2.8 ns Creatinine in mg/dL, mean ± SD 1.9 ± 1.4 1.9 ± 1.1 ns Procalcitonin in ng/mL, median (IQR) 25.8 (5.8-93.4) 15.2 (5.9-39.0) ns

Day 1 SOFA, mean ± SD 8.3 ± 2.8 8.7 ± 3.7 ns

APACHE II, mean ± SD 22.1 ± 6.3 22.6 ± 5.7 ns

APACHE IV, mean ± SD 79.5 ± 16.4 82.0 ± 27.4 ns

Predicted mortality, mean ± SD 39.7 ± 16.7 41.6 ± 24.2 ns

Results (n=94)

Triple therapy (n=47) Control (n=47) p-value Hospital mortality, n (%) 4 (8.5) 19 (40.4) <0.001 ICU LOS in days, median (IQR) 4 (3-5) 4 (4-10) ns

Duration of vasopressors in hours, mean ± SD 18.3 ± 9.8 54.9 ± 28.4 <0.001 RRT for AKI, n (%) 3 of 31 (10%) 11 of 30 (33%) 0.02

DSOFA, 72 hours 4.8 ± 2.4 0.9 ± 2.7 <0.001 Procalcitonin clearance 72 hours, median % (IQR) 86.4 (80.1 to 90.8) 33.9 (-62.4 to 64.3) <0.001

Conclusions • Early use of IV vitamin C with thiamine and hydrocortisone appear to be effective in preventing progressively worsening organ dysfunction and reduce mortality associated with sepsis and septic shock

Critique

Strengths Limitations

• Propensity score to adjust for likelihood of triple therapy • No control patients received IV thiamine or vitamin C • Safety of individual agents previously described • Plausible biochemical mechanisms can explain effects; both

vitamin C and hydrocortisone are necessary for endogenous catecholamine production and utilization

• Septic patients often have depletion of triple therapy components

• Small sample sizes • Single-center design • Control subjects not enrolled concurrently • Did not assess typical volume resuscitation protocol • Time to antimicrobials and agent used not commented on • Did not provide vasopressor breakdown explicitly • Vasopressor escalation differs from most published data

AKI=acute kidney injury; APACHE=acute physiology and chronic health evaluation; D=delta/change; D5W=dextrose 5% in water; DNR=do not resuscitate; ICU=intensive care unit; IV=intravenous; LOS=length of stay; NS=normal saline; RRT=renal replacement therapy SOFA=sepsis-related organ failure assessment

RYAN-HUMMEL 15

Katsenos 201421 Fowler 201431 Donnino 201636 Marik 201640

Design Non-randomized, prospective, longitudinal

Placebo-controlled, double-blind, randomized, phase I trial

Two-center, placebo-controlled, double-blind, randomized, pilot

Retrospective, before-after study

Population Septic shock adults; norepinephrine >0.5 mcg/kg/min

Severe sepsis Sepsis + lactate >3 mmol/L + hypotension + vasopressors

Severe sepsis or septic shock + procalcitonin >2 ng/mL

Intervention IV hydrocortisone 50 mg q6h x 7d Early <9 hours (n=46) Late >9 hours (n=124)

IV vitamin C divided q6h Placebo (n=8) Lo-AscA: 50 mg/kg/d (n=8) Hi-AscA: 200 mg/kg/d (n=8)

Thiamine 200 mg q12h x 7d Placebo (n=45) Thiamine (n=43)

Triple therapy* Control (n=47) Triple therapy (n=47)

Baseline

APACHE II SOFA

26.3 vs 23.9 11.5 vs 10.7

APACHE II SOFA

20.4 vs 20.4 vs 24 13.3 vs 10.1 vs 10.8

APACHE II SOFA

26.5 vs 25.7 10.2 vs 10.1

APACHE II SOFA

22.6 vs 22.1 8.7 vs 8.3

Outcomes ⇓ vasopressor duration ⇓ mortality

⇓ SOFA score ⇓ c-reactive protein ⇓ procalcitonin

⇓ mortality in deficient patients ⇓ vasopressor duration ⇓ mortality ⇓ SOFA score ⇓ procalcitonin

*Triple therapy= IV hydrocortisone 50 mg q6h x 7d + IV vitamin C 50 mg q6h x 4d + IV thiamine 200 mg q12h x 4

Treatment recommendations

I. Patient with septic shock a. Appropriate fluid resuscitation based on patient specific parameters with a goal MAP >65 mmHg b. If MAP >65 mmHg not achieved, initiate norepinephrine and titrate to MAP >65 mmHg c. If not at goal with norepinephrine ≥0.5 mcg/kg/min for >1 hour then add further therapy d. Add vasopressin and triple therapy to norepinephrine drip

i. Vasopressin 0.04 units/min ii. Hydrocortisone IV 50 mg every 6 hours for 7 days

iii. Vitamin C IV 1.5 g every 6 hours for 4 days 1. Reconstitute in 100 mL D5W or NS over 30 to 60 minutes

iv. Thiamine IV 200 mg every 12 hours for 4 days 1. Reconstitute in 50 mL D5W or NS over 30 minutes

II. Further consideration should be provided for the following patients; must outweigh risks a. Chronic immunosuppression b. Glucose-6-phosphate dehydrogenase deficiency c. Underlying/previously identified chronic kidney disease d. >72 hours after septic shock onset e. A diagnosis of “severe sepsis” and not septic shock

RYAN-HUMMEL 16

References

1. Bone RC, Balk RA, Cerra FB, et al. 1991 ACCP/SCCM consensus conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992;101:1644-55.

2. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definition conference. Crit Care Med 2003;31(4):1250-6. 3. Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med

2017;3:00-00. 4. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315(8):801-10. 5. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis for the third international consensus definitions for sepsis and septic shock

(Sepsis-3). JAMA 2016;315(8):762-74. 6. Novosad SA, Sapiano MR, Grigg C, et al. Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention. MMWR Morb

Mortal Wkly Rep 2016;65:864-9. 7. Taeb AM, Hooper MH, Marik PE. Sepsis: current definition, pathophysiology, diagnosis, and management. Nutr Clin Pract 2017;32:296-308. 8. Gotts JE, Matthay MA. Sepsis: pathophysiology and clinical management. BMJ 2016;353:i1585. 9. O’Brien JM, Lu B, Ali NA, et al. Alcohol dependence is independently associated with sepsis, septic shock, and hospital mortality among adult intensive care unit

patients. Crit Care Med 2007;35:345-50. 10. Dellinger RP, Schorr CA, Levy MM. A users’ guide to the 2016 surviving sepsis guidelines. Crit Care Med 2017;3:00-00. 11. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human

septic shock. Crit Care Med 2006;34(6):1589-96. 12. Tang BMP, Eslick GD, Craig JC, et al. Accuracy of procalcitonin for sepsis diagnosis in critically ill patients: systematic review and meta-analysis. Lancet Infect Dis

2007;7:210-7. 13. Schuetz P, Birkhahn R, Sherwin R, et al. Serial procalcitonin predicts mortality in severe sepsis patients: results from the multicenter procalcitonin monitoring

sepsis (MOSES) study. Crit Care Med 2017;45:781-9. 14. Batzofin BM, Sprung CL, Weiss YG. The use of steroids in the treatment of severe sepsis and septic shock. Best Pract Res Clin Endocrinol Metab 2011;25:735-43. 15. Marik PE, Pastores SM, Annane D, et al. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients:

consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med 2008;36:1937-49. 16. Annane D, Maxime V, Ibrahim F, et al. Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med 2006;174:1319-26. 17. Marik PE. Glucocorticoids as adjunctive therapy for acute respiratory distress syndrome and sepsis? Yes, but not as monotherapy. Crit Care Med 2017;45(5):910-1. 18. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low dose of hydrocortisone and fludrocortisone on mortality in patients with septic shock.

JAMA 2002;288:862-71. 19. Sprung Cl, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock (CORTICUS study group). N Engl J Med 2008;358:111-24. 20. Keh D, Trips E, Marx G, et al. Effect of hydrocortisone on development of shock among patients with severe sepsis: the HYPRESS randomized clinical trial. JAMA

2016;316(17):1775-85. 21. Katsenos CS, Antonopoulou AN, Apostolidou EN, et al. Early administration of hydrocortisone replacement after the advent of septic shock: impact on survival

and immune response. Crit Care Med 2014;42:1651-7. 22. Fisher BJ, Kraskauskas D, Martin EJ, et al. Attenuation of sepsis-induced organ injury in mice by vitamin C. J Parenter Enteral Nutr 2014;38:825-39. 23. Wilson JX. Evaluation of vitamin C for adjuvant sepsis therapy. Antioxid Redox Signal 2013;19(17):2129-40. 24. Carr AC, Shaw GM, Fowler AA, et al. Ascorbate-dependent vasopressor synthesis: a rationale for vitamin C administration in severe sepsis and septic shock? Crit

Care 2015;19:418. 25. Wilson JX, Wu F. Chapter 5-vitamin C in sepsis. O. Stanger (ed.), Water Soluble Vitamins, Subcellular Biochemistry 56;67-83. Springer, New York, New York. 26. Honore PM, Jacobs R, Hendrickx I, et al. Adjuvant vitamin C treatment in sepsis-how many oranges a day keep (vasopressor-dependent) septic shock away? J

Thorac Dis 2016;8(9):e993-5. 27. Oudemans-van Straaten HM, Spoelstra-de Man AME, de Waard MC. Vitamin C revisited. Crit Care 2014;18:460. 28. Long CL, Maull KI, Krishnan RS, et al. Ascorbic acid dynamics in the seriously ill and injured. J Surg Res 2003;109:144-8. 29. Zabet MH, Mohammadi M, Ramezani M, et al. Effect of high-dose ascorbic acid on vasopressor’s requirement in septic shock. J Res Pharm Prac 2016;5:94-100. 30. Bharara A, Grossman C, Grinnan D, et al. Case report: intravenous vitamin C administered as adjunctive therapy for recurrent acute respiratory distress syndrome.

Case Rep Crit Care 2016;ID8560871. 31. Fowler AA, Syed AA, Knowlson S, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med 2014;12:32. 32. Manzanares W, Hardy G. Thiamine supplementation in the critically ill. Curr Opin Clin Nutr Metab Care 2011;14:610-7. 33. Collie JTB, Greaves RF, Jones OAH, et al. Vitamin B1 in critically ill patients: needs and challenges. Clin Chem Lab Med 2017; ahead of print. 34. Donnino MW, Carney E, Cocchi MN, et al. Thiamine deficiency in critically ill patients with sepsis. J Crit Care 2010;25:576-81. 35. de Andrade JAA, Gayer CRM, de Almeida Nogueira NP, et al. The effect of thiamine deficiency on inflammation, oxidative stress and cellular migration in an

experimental model of sepsis. J Inflamm 2014;11:11. 36. Donnino MW, Andersen LW, Chase M, et al. Randomized, double-blind, placebo-controlled trial of thiamine as a metabolic resuscitator in septic shock: a pilot

study. Crit Care Med 2016;44:360-7. 37. Barabutis N, Khangoora V, Marik PE, et al. Hydrocortisone and ascorbic acid synergistically prevent and repair LPS-induced pulmonary endothelial barrier

dysfunction. Chest 2017; accepted manuscript. 38. Okamoto K, Tanaka H, Makino Y, et al. Restoration of the glucocorticoid receptor function by the phosphodiester compound of vitamins C and E, EPC-K1 (L-

ascorbic acid 2-[3,4-dihydro-2,5,7,8-tetramethyl-2-(4,8,12-trimethyltridecyl)-2H-1-benzopyran-6-yl hydrogen phosphate] potassium salt), via a redox-dependent mechanism. Biochem Pharmacol 1998;56(1):79-86.

39. Fujita I, Hirano J, Itoh N, et al. Dexamethasone induces sodium-dependent vitamin C transporter in a mouse osteoblastic cell line MC3T3-E1. Br J Nutr 2001;86:145-9.

40. Marik PE, Khangoora V, Rivera R, et al. Hydrocortisone, vitamin C, and thiamine for the treatment of severe sepsis and septic shock: a retrospective before-after study. Chest 2017;151(6):1229-38.

RYAN-HUMMEL 17

Appendices

I. Appendix A. SIRS criteria (range 0-4 points)1,2

°C=degrees Celsius; HR=heart rate; PCO2=partial pressure of carbon dioxide; RR=respiratory rate; WBC=white blood cell count **SIRS criteria met when at least two of the criteria are present

II. Appendix B. SOFA score (range 0-24 points)4,5

Respiratory Neurological Cardiovascular Hepatic Coagulation Renal

Organ failure score PaO2/FiO2 (mmHg) GCS Vasopressor (mcg/kg/min) Bilirubin (mg/dL) Platelets (x103/µL) Creatinine (mg/dL)

0 ≥400 15 MAP ≥70 mmHg <1.2 ≥150 <1.2 1 <400 13-14 MAP <70 mmHg 1.2-1.9 <150 1.2-1.9 2 <300 10-12 D <5; DO 2.0-5.9 <100 2.0-3.4 3 <200+MV 6-9 D 5.1-15; E ≤0.1; NE ≤0.1 6.0-11.9 <50 3.5-4.9 4 <100+MV <6 D >15; E >0.1; NE >0.1 >12.0 <20 >5.0

D=dopamine; DO=dobutamine; E=epinephrine; GCS=Glasgow coma scale; MAP=mean arterial pressure; MV=mechanically ventilated; NE=norepinephrine; PaO2/FiO2=fraction of inspired oxygen

III. Appendix C. qSOFA criteria (range 0-3) 4,5

GCS=Glasgow coma scale; RR=respiratory rate; SBP=systolic blood pressure

IV. Appendix D. Vasopressor administration in septic shock10

IV=intravenous; MAP=mean arterial pressure

T >38° C or T <36° C

RR >20 breaths/min or PCO2 <32 mmHg

WBC >12 ,000/mm3 or WBC <4,000/mm3 or bands >10%

HR >90 beats/min

Altered mental status (GCS £13)

RR ³22 breaths/min

SBP £100 mmHg

MAP <65 mmHg

•Titrate norepinephrine to 0.5-1.3 mcg/kg/min

MAP <65 mmHg

•Add vasopressin 0.03 units/min•Consider IV hydrocortisone

MAP <65 mmHg

•Titrate epinephrine to 0.3-0.7 mcg/kg/min•Add IV hydrocortisone

MAP <65 mmHg

•Titrate phenylephrine 2.9-4.3 mcg/kg/min