The Effect of Vitamin C, Thiamine and Hydrocortisone on Clinical Course and Outcome in Patients With Severe Sepsis and Septic Shock
The Effect of Vitamin C, Thiamine and Hydrocortisone on Clinical Course and Outcome in Patients With Severe Sepsis and Septic Shock
The global burden of sepsis is substantial with an estimated 15 to 19 million cases per year;
 the vast majority of these cases occur in low income countries. New therapeutic approaches to
 sepsis are desperately required; considering the global burden of sepsis these interventions
 should be effective, cheap, safe and readily available. The aim is to study the synergistic
 effect of vitamin C, hydrocortisone and thiamine on survival in patients with severe sepsis
 and septic shock.
AIM OF THE STUDY:

 The goal is to determine the effects on clinical course and outcome of patients with severe
 sepsis and septic shock treated with vitamin C, hydrocortisone and thiamine.

 BACKGROUND:

 This study will be conducted in the intensive care unit of Department of Gastroenterology,
 University Medical Center (UMC) Ljubljana. All of the patients with severe sepsis and septic
 shock admitted to the Intensive Care Unit (ICU) in the past 12 hours will be screened for
 possible inclusion in the study. The diagnosis of severe sepsis and septic shock will be
 based on the 1992 American College of Chest Physicians/Society of Critical Care Medicine
 Consensus Conference definitions.

 PLAN OF THE STUDY:

 After determining the eligibility for inclusion in our study, the investigators will acquire
 the written consent from the patient or relatives. The investigators (doctor on call) will
 randomize the patient either in the treatment or placebo group. The randomization will be
 done before-hand with the online tool Research Randomizer. After acquiring the randomized
 numbers, they will be placed in sealed envelopes. These envelopes will be available to the
 on-call doctor. The envelopes will then be sent to our outpatient clinic, where the studied
 substances will be mixed by a nurse, that will have no contact with the patients or the ICU
 staff. The substances will be marked with Vitamin C, Thiamine and Hydrocortisone, regardless
 if normal saline or the actual substances are inside the vials. Only this nurse will have the
 data regarding the contents of the vials.

 Based on literature the investigators expect that survival and clinical course in sepsis and
 septic shock is correlated with fluid resuscitation and vasopressor use. Because of this, all
 of the included patients will be monitored with invasive hemodynamic monitoring (All of the
 patients will be monitored with the Edwards EV 1000 monitors).

 All of the patients will be treated the same as per internationally recognized guidelines for
 treatment of septic shock. While the use of corticosteroids in severe sepsis is off-label,
 the patients will be informed of possible side-effects. This fact will also be written in the
 consent.

 Neither the patients or the relatives will receive no financial compensation for study
 inclusion. During the hospitalization, the patients will receive three different substances
 in dosages, that are non toxic. During the study, there will be intermittent statistical
 analysis, and if increased mortality or severe side effects will be found then the study will
 be terminated. The confidentiality of personal data will be protected accordingly with the
 rules and laws of patient's privacy. The identity of patients will not be disclosed. The data
 acquired during the study will be available to the study participant. The anticipated costs
 will be covered by the Department of Gastroenterology, UMC Ljubljana. No financial
 compensation will be given to researchers.

 During the study the following data will be acquired from the patients:

 1. Age,

 2. Sex,

 3. Body weight,

 4. Admitting diagnosis and source of infection,

 5. Isolated pathogens,

 6. Comorbidities,

 7. The need for mechanical ventilation,

 8. The use of vasopressors (all doses will be converted to Norepinephrine equivalents),

 9. The duration of vasoactive therapy,

 10. Daily urine output,

 11. Fluid balance after 24 and 72 hours,

 12. The presence of acute kidney failure

 13. Duration of ICU stay and hospital stay,

 14. Survival in ICU, hospital, after 28 and 60 days

 15. Routine blood test for the first 4 days, a. creatinine b. White Blood Cells (WBC) c.
 Platelets d. Bilirubin e. Partial Pressure of Oxygen in Arterial Blood/Fraction of
 Inspired Oxygen (PaO2/FiO2) ratio e. procalcitonin (PCT) and procalcitonin clearance f.
 lactate g. blood samples will be stored for possible additional analysis

 The patients' admission Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE
 IV scores will be recorded. The APACHE IV score allows calculation of the predicted hospital
 mortality and predicted ICU length of stay (LOS). The daily Sepsis-related Organ Failure
 Assessment (SOFA) score will be recorded for the first 4 treatment days.

 Data analysis:

 Summary statistics will be used to describe the clinical data and presented as mean ±
 standard deviation (SD), median with interquartile range (IQR) or percentages as appropriate.
 Chi squared analysis with Fisher's exact test (when appropriate) and Student's t test (Mann
 Whitney U test for non-normal distributions) were used to compare data between the active
 treatment group and the placebo group with statistical significance declared for probability
 values of 0.05 or less.

 Data Safety & storage:

 The main risk to subjects is the accidental release of Protected Health Information (PHI).
 Careful record management methods will be in place to ensure this type of privacy breach does
 not occur. The data set will be kept in a password-protected file and stored separately from
 the subject identification (ID) key in the locked office of the principal investigator. Only
 the research team will have access to this information, and will not disclose this
 information to any other person or entity. Three years after the completion of the study, all
 collected data will be destroyed by permanently deleting electronic copies.

 EXPECTED RESULTS:

 The investigators expect a faster recovery, shorter hospitalization, shorter use of
 vasoactive drugs and better survival in treatment group versus (vs.) control group.
Inclusion Criteria:

 -  Diagnosis of severe sepsis or septic shock within 12 hours of admission in our
 Intensive Care Unit (ICU).

 -  Informed consent.

 Exclusion Criteria:

 -  Age < 18 years

 -  Pregnancy

 -  Do Not Resuscitate (DNR/DNI) with limitations of care

 -  Patients with fatal underlying disease who are unlikely to survive to hospital
 discharge (e.g.: disseminated malignant disease)

 -  Patients primarily admitted for acute coronary syndromes, acute cerebrovascular
 incidents or active gastrointestinal (GI) bleeds

 -  Patients that need immediate surgical treatment

 -  Patients with HIV and a cell count of cluster of differentiation 4 (CD4) cells < 50
 mm2,

 -  Patients with known glucose-6 phosphate dehydrogenase (G-6PD) deficiency.

 -  Patients with severe sepsis/septic shock transferred from another hospital

 -  Patients with features of sepsis/septic shock > 24 hours

 -  Patients who require treatment with corticosteroids for an indication other than
 sepsis (chronic corticosteroid use, known Addison's Disease, Ulcerative colitis,
 Crohn's disease...)