Shock Syndromes I

Patient Case

A 62-year-old woman was admitted to the surgical ICU with presumed aspiration pneumonia. The patient

has a history of insulin-dependent diabetes and hyperthyroidism. On admission, she was intubated and

required aggressive resuscitation and vasopressor therapy. Currently, the patient is receiving norepineph-

rine 8 mcg/minute and has the following vital signs and laboratory values: blood pressure 100/60 mm Hg,

heart rate 90 beats/minute, and CVP 14 mm Hg; her Scvo2 is 55%. Which is best regarding the patient’s

steroid therapy?

Vitamin C, hydrocortisone, and thiamine

A retrospective before-after study evaluated the effect of the combination of intravenous

vitamin C (1.5 g every 6 hours for 4 days or until ICU discharge), hydrocortisone (50 mg every

6 hours for 7 days or until ICU discharge, followed by a taper over 3 days), and intravenous

thiamine (200 mg every 12 hours for 4 days or until ICU discharge) for patients with sepsis.

Patients receiving this medication combination had a lower propensity-adjusted odds of

mortality (OR 0.13; 95% CI, 0.04–0.48; p=0.002). This study is limited by the before-after

design and a control group mortality rate (8.5%) lower than in contemporary sepsis studies

(leading to questions about the study population).

ii.

Several subsequent randomized controlled trials have evaluated this clinical question,

including the VITAMINS, VICTAS, and ACTS trials, which have all shown no benefit with

the use of vitamin C, hydrocortisone, and thiamine.

iii.

Two randomized controlled trials, the CITRIS-ALI and the LOVIT trials, evaluated vitamin

C without hydrocortisone or thiamine in patients with sepsis and found no clinical benefit to

the use of vitamin C. In fact, the LOVIT trial found higher rates of death or persistent organ

dysfunction at 28 days in the vitamin C cohort (44.5% vs. 38.5%; RR 1.21; 95% CI, 1.04−1.40).

iv.

The 2021 SSC guidelines suggest against the use of intravenous vitamin C in patients with

sepsis and septic shock. They do not discuss the role of thiamine or the combination of vitamin

C, hydrocortisone, and thiamine.

Intravenous immunoglobulins should not be used in patients with sepsis and septic shock. In a

randomized study of patients with sepsis, 28-day mortality was no different between patients

allocated to intravenous immunoglobulin G and placebo (39.3% vs. 37.3%, p=0.67).

A transfusion threshold of 7 g/dL or less is appropriate for patients with septic shock unless

extenuating circumstances exist (i.e., myocardial ischemia, severe hypoxemia, or acute hemorrhage).

A multicenter study compared two different transfusion thresholds in patients with septic

shock. The study enrolled patients with septic shock and a hemoglobin concentration below 9

g/dL to receive PRBC transfusion if their hemoglobin was 7 g/dL or less (lower threshold) or

9 g/dL or less during their ICU stay.

ii.

As expected, patients allocated to the lower-threshold group less commonly received PRBC

transfusion and had lower hemoglobin concentrations.

iii.

Treatment arms did not differ in 90-day mortality (43.0% in the lower threshold group vs.

36.6% in the higher-threshold group, p=0.44). Patients in the lower-threshold group had no

higher incidence of ischemic events in the ICU (7.2% vs. 8.0%, p=0.64), and outcomes did not

differ between groups in the subgroup of patients with chronic cardiovascular disease (RR

1.08 [95% CI, 0.75–1.40]; p=0.25 for heterogeneity of treatment effect by subgroup; only 14%

of the overall population had chronic cardiovascular disease).