Hager – Vitamin C, Thiamine, and Steroids in Sepsis

David Hager, MD, PHD, Assistant Professor, Division of Pulmonary and Critical Care at the Johns Hopkins University School of Medicine presents on “Vitamin C in Sepsis: Rationale for the VICTAS Trial.”

Clinical Pearls

Summary by Dr. Andy Deitchman

Background

High dose vitamin C, Thiamine, and hydrocortisone. Marik. Chest 2017

Inclusion Criteria

Sepsis with respiratory support (e.g. HFNC, NiPPV, mechanical ventilation) and/or need for continuous vasopressors > 1 hr.

Design

Intervention v placebo (+/- stress dose steroids) x 4 days or ICU discharge, whichever comes first.
Intervention consists of:
- Vitamin C 1.5 g every 6 hours
- Thiamine 100 mg every 6 hours
- Hydrocortisone 50 mg every 6 hours

Outcomes

Primary: ventilator and vasopressor free days
Key secondary outcomes: Mortality at 30 days

Physiology

Humans and guinea pigs, only mammals that do not make vitamin C
Fun fact: Peppers are a better natural source of vit. C than oranges
Vitamin C is rapidly consumed in the setting of acute illness.

Functions of vitamin C

Cofactor to produce dopamine, norepinephrine, vasopressin, and corticosteroids
Enhances sensitivity to catecholamines
Anti-oxidant, free radical scavenger
Attenuates acute lung injury in septic animal models
Improve endothelial vascular integrity
Improves WBC function
Thiamine
- Improved lactate clearance by driving pyruvate into the TCA cycle
- Reduces possible renal injury from oxalic acid formation caused by high dose vitamin C
Pitfalls
- High dose vitamin C – erroneously high glucose readings on POC glucometer

Selected References

Marik, Paul E., et al. “Hydrocortisone, vitamin C, and thiamine for the treatment of severe sepsis and septic shock: a retrospective before-after study.” Chest 151.6 (2017): 1229-1238.[ScienceDirect]

Marik, Paul E. “Vitamin C for the treatment of sepsis: the scientific rationale.” Pharmacology & therapeutics 189 (2018): 63-70.[ScienceDirect]