🚨BIG NEWS: In January, the unpublished VICTAS trial of vitamin C in #sepsis was stopped after enrolling just 501 of a planned 2000
Now data on clinicaltrials.gov shows why, and it doesn’t look good for #vitaminC. Is this the last🔩in⚰️of the ‘metabolic cure’?
A short🧵
1/
I’ve been hopeful but more than a little skeptical about the 🍹🍋 metabolic cocktail for sepsis (vitamin C + hydrocortisone + thiamine) since the original before/after case series.
I’ve followed this literature closely & have been waiting eagerly for the results of the RCTs.
2/
Thats’s why I was excited to see that VICTAS had posted results. bit.ly/3j3Iatl
The VICTAS trial is the largest (& arguably best) of the vitamin C RCTs: a placebo-controlled, Double-blind RCT done at 43 sites across the US. The 1° endpoint was vasopressor free days.
3/
The results are incomplete & we will need to wait for the actual publication to get the full picture.
But what we can see doesn’t look good:
* similar mortality rate in both arms
* more vasopressor free days in the control group
* some adverse events in the vitamin C arm 4/
Even with this limited data and some simple stats, we can see that there is no significant difference in all cause mortality:
- HAT 22.2% vs Placebo 24.1% (RR 0.92 95% CI 0.67 - 1.27; p = 0.67)
There also isn’t a difference in vasopressor free days:
- HAT 25 vs Placebo 26 5/
When we think about these results in the context of the other published studies it 🎨a consistent🖼:
- *not one* study has replicated the effect seen by Marik et al
See my updated Forrest Plot (full blog post soon): The more studies we do the smaller the overall effect. 6/
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Did he have a head CT? What did it show?
Did he have stitches? Tetanus shot?
The NYT ran nonstop stories about Biden’s health after the debate but can’t be bothered to report on the health of someone who was literally shot in the head?
To the people in the replies who say it’s impossible because of “HIPPA” 1. I assume you mean HIPAA 2. A normal presidential candidate would allow his doctors to release the info. This is exactly what happened when Reagan survived an assassination attempt. washingtonpost.com/obituaries/202…
My advice to journalists is to lookup tangential gunshot wounds (TGSW).
Ask questions like:
- what imaging has he had?
- what cognitive assessments?
- has he seen a neurosurgeon or neurologist?
- he’s previously had symptoms like slurred speech, abnormal gait - are these worse?
If you intubate you need to read the #PREOXI trial!
-n=1301 people requiring intubation in ED/ ICU were randomized to preoxygenation with oxygen mask vs non-invasive ventilation (NIV)
-NIV HALVED the risk of hypoxemia: 9 vs 18%
-NIV reduced mortality: 0.2% vs 1.1%
#CCR24
🧵 1/
Hypoxemia (SpO2 <85%) occurs in 10-20% of ED & ICU intubations.
1-2% of intubations performed in ED/ICU result in cardiac arrest!
This is an exceptionally dangerous procedure and preoxygenation is essential to keep patients safe.
But what’s the *BEST* way to preoxygenate? 2/
Most people use a non-rebreather oxygen mask, but because of its loose fit it often delivers much less than 100% FiO2.
NIV (“BiPAP”) delivers a higher FiO2 because of its tight fit. It also delivers PEEP & achieves a higher mean airway pressure which is theoretically helpful! 3/
Results from #PROTECTION presented #CCR24 & published @NEJM.
- DB RCT of amino acid infusion vs placebo in n=3511 people undergoing cardiac surgery w/ bypass.
- Reduced incidence of AKI (26.9% vs 31.7% NNT=20) & need for RRT (1.4% vs 1.9% NNT=200)
Potential game changer!
🧵 1/
I work in a busy CVICU & I often see AKI following cardiac surgery.
Despite risk stratification & hemodynamic optimization, AKI remains one of the most common complications after cardiac surgery with bypass.
Even a modest reduction in AKI/CRRT would be great for my patients. 2/
During cardiac surgery w/ bypass, renal blood flow (RBF) is reduced dramatically. This causes injury, especially in susceptible individuals.
But what if we could use physiology to protect the kidneys?
Renal blood vessels dilate after a high protein meal increasing RBF & GFR! 3/
77 yo with respiratory distress, RR 30, SpO2 80% on non-rebreather at 15 lpm
CXR & TTE are unrevealing
pH 7.58 / PaCO2 24 / PaO2 >500 / HCO3 22
MetHb 0% CarboxyHb 0%
The ABG looks like this:
The answer is sulfhemoglobinemia.
Sulfhemoglobinemia is a *permanently* modified hemoglobin associated with exposure to TMP/SMX, dapsone, phenazopyridine, & other amino & nitro compounds.
It has an altered oxy-hemoglobin dissociation curve.
2/
Sulfhemoglobinemia is easily confused with methemoglobinemia. Both have very dark colored blood & present with cyanosis. Diagnosis typically requires a specialized lab.
Spoiler: you may have heard that SulfHb is green. It isn’t really. You’re thinking of Vulcans’ blood.