Showing posts with label thiamine. Show all posts
Showing posts with label thiamine. Show all posts

Saturday, October 19, 2019

Thiamine and Renal Failure in Septic Shock Patients

Every possible option to decreased morbidity, mortality, and costs are worth looking at in my book. The study that I am reviewing at this moment was published in 2017. I am ashamed that I had not run into it until today. It's challenging to stay up to date in everything. I digress.

Some would quickly bash this study for it being small (n=70) and a post-hoc secondary analysis of a pilot study. I am not going to do that. Why not? Well first of all, I do not participate in research myself. Just reading and enjoying these studies. Also, thiamine has no side effects described in the literature. Third, it is an inexpensive medication. Fourth, if it does turn out to decrease the incidence of acute kidney injury and the need for renal replacement therapy, aren't you going to feel guilty for not adopting these strategies for your patients? I hate resorting to that but my responsibility is for patients. What happens if this data is wrong? Nothing. What happens if this data is right and no one does anything for several years? Many patients may suffer.


This article is completely free and I encourage you to download it and read it for yourself. Amongst the points illustrated by the authors, they mention that it's not only perfusion that injures the kidneys during sepsis. There are other factors listed in the article. The way that it is postulated that thiamine works for these patients is by assisting in the mitochondrial dysfunction. Data that I have found not listed in this article shows that thiamine deficiency could have an incidence between 20-70% of critically ill patients. 

What they found was 21% of the patients in the placebo arm of the trial went on to need dialysis. Just one patient, or 3% in the thiamine group went on to require this. The authors note that acidosis was the primary indication for dialysis in 66% of the patients who required it. I personally would like to dig deeper into these numbers as there is some data that thiamine administration helps decrease lactic acidosis. 

This data should make you wonder if the strategy that many clinicians take of providing more IV fluids to patients whose renal function deteriorates is the correct strategy. Are we going to look in the mirror in a decade and want to punch our past selves in the face?   

- EJ






Link to Abstract


Link to Full Article

ADDENDUM: The prospective RCT is going to be completed in July 2022. Here is the link to clinicaltrials.gov's study details here: LINK

Moskowitz A, Andersen LW, Cocchi MN, Karlsson M, Patel PV, Donnino MW. Thiamine as a renal protective agent in septic shock. A secondary analysis of a randomized, double-blind, placebo-controlled trial. Anns Am Thorac Soc. 2017;14(5):737–41.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works.

You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
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Thiamine, Ascorbic Acid and Corticosteroids: The Mechanisms by which they should help in Sepsis

Want some nerdy stuff? Well this is some nerdy stuff! I'm taking a nice deep look at this figure. I am not going to lie to you at this moment, October 19th, and tell you I know what all this means, because I don't. But people who are more intelligent that I am have suggested that these are the mechanisms by which thiamine, ascorbic acid, and corticosteroids should help in the treatment of septic patients. I have a lot to learn.

I hope I don't get dinged for copyright stuff but honestly if this offends you, let me know. I will take it down. I will likely go deeper into this article at a later time. Wanted to share this image with you right now, though.





Link to Abstract

Link to FREE FULL Article

Moskowitz, A.; Andersen, L.W.; Huang, D.T.; Berg, K.M.; Grossestreuer, A.V.; Marik, P.E.; Sherwin, R.L.; Hou, P.C.; Becker, L.B.; Cocchi, M.N.; et al. Ascorbic acid, corticosteroids, and thiamine in sepsis: A review of the biologic rationale and the present state of clinical evaluation. Crit. Care 2018, 22, 283.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.
The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works.

You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
- My Amazon Store

Monday, July 29, 2019

Ascorbic Acid, Thiamine, and Steroids in Septic Shock: Propensity Matched Analysis


Link to Article


Another day, another Vitamin C article. This one came out just two weeks ago, it’s not free, and the results are a bit strange. There are larger trials in the works. If I were part of the group of these authors, I’d be itchy to get my data out ASAP as well. Just 31 patients in each arm of this trial. Heck, even I could replicate this trial in my 20 bed MSICU if I wanted to over 1.5 years. The problem is that my bias admittedly is for the cocktail to work. I am wide openly admitting that, everyone. I have a bias. I want it to work bc I want my patients to live.  
There are numerous parts of this study that seem strange to me. 
1. the ICU mortality of the control arm is 42%. This number should not be quite as high based on the latest data. That could lead the p-value of 0.004 to be perhaps a bit too small. But considering that they used the same strategies to manage septic shock these pts in both arms, it’s still valid for that institution. 
2. The duration of the vasopressors were longer in the experimental arm. This makes NO sense as Vitamin C is a co-factor in the endogenous creation of catecholamines. Heck, even the authors admitted this was strange. 
3. There was no significant difference in hospital mortality. They probably needed a high n to get this to show a difference. The hospital medicine and palliative teams must be great at getting code status’ changed so that people don’t bounce back to the unit. 
4. Pts did not get off of the ventilator faster. Word on the street is that there’s preliminary data suggesting that it helps this process that just isn’t out yet. Stay tuned. 
Lastly, everyone is worried about renal failure. No difference in AKI here, folks. In fact, I am yet to see one report in any of these trials talking about renal calculi secondary to vitamin C in sepsis. 

What are your thoughts on the matter? Is your shop using this yet? Are you a believer or a skeptic?





Tuesday, March 26, 2019

Marik Protocol for Septic Shock: Looking at Vitamin C

Hydrocortisone, Ascorbic Acid and Thiamine
(HAT Therapy) for the Treatment of Sepsis. Focus on Ascorbic Acid

Controversies. Controversies. Controversies. I tell you, the behaviors of Intensivists when it comes to king septic patients IV Vitamin C for sepsis are quite perplexing. We had a cheap drug, <$20 a day that MAY help treat sepsis and people don’t even bother to try it out. I know I use it because if it saves lives, why not try? Let’s say that the trials show a mortality benefit, two years have already passed since the first trial. Think of all the additional lives you could have saved but didn’t because your ego was in the damned way. If Marik is wrong, nothing bad happened. But if he’s right, you’re going to beat yourself up.

-EJ 



Link to Abstract

Link to PDF