Thread by @CHESTCritCare

Vitamins in Critical Illness starting now!

Discussing: Vitamin C, Vitamin B12, Vitamin D

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Vitamin B12 up first by Dr. Jayshil Patel.
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There are elevated hydrogen sulfide (H2S) in early sepsis.

As a consequence, H2S induces cytokine activation.

H2S positively correlates with shock severity and mortality.

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How does vitamin B12 play into this?

Dosing is important:

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High-dose B12 mechanism has shown to have elevated blood pressure effects in cyanide and hydrogen sulfide toxicity.

First use of B12 was first used in circulatory shock in the 1960s!!

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Postulated mechanisms:

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Human data is limited to post-operative surgical vasoplegia. Reduction in vasopressor dose and improvement in MAP (single arm studies, observational).

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Side effects of vitamin B12? Generally safe.
Chromaturia and flushing most commonly seen.

Need randomized controlled trials.

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Dr. Todd Rice is up next discussing vitamin D in critical illness.

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Vitamin D is actually a pre-hormone!
(Vitamins are co-factors that must be ingested... who knew?)

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Vitamin D receptors are on nearly every cell type!

Vitamin D deficiency is defined as <20ng/mL

More than half of critically ill patients are vitamin D deficient.

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Is there vitamin D toxicity?
Short answer is rare, wide therapeutic window.

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VITdAL-ICU trial

VIOLET and VIDALIZE are two randomized controlled trials.
VIOLET did not show a mortality benefit with vitamin D.
VIDALIZE is ongoing (some differences in design).

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What about vitamin D and #COVID19 ???

Observational studies showing an association with improvement in outcomes.

Need more studies (41 interventional studies ongoing with vitamin D and COVID-19)

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Lastly, Dr. Alpha (Berry) Fowler discussing vitamin C in critical illness. 🍊🍋

The CITRIS-ALI Trial looking at vitamin C in sepsis-induced acute lung injury.

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Vitamin C infusion decreases lung cytokines/chemokines expression, reduces lung neutrophil infiltration, increases alveolar fluid clearance and restore lung barrier function.

In human studies, it reduced organ failure and c-reactive protein.

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CITRIS-ALI was a multi-center trial.

➡️Primary outcomes: SOFA Score and Plasma C-reactive protein and thrombomodulin.

➡️Patient included with severe sepsis, ARDS (P/F <300)
N=170

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Re-analysis with addressing survivorship bias show significant difference in mSOFA score.

No difference in c-reactive protein or thrombomodulin.

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Kaplan-Meier curve:

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How do all of these vitamins interact or a role for combination therapy??

Unclear on the role of vitamin cocktails for critically ill patients.

Thanks for tuning in! It is 5 pm ET, perhaps time for your own cocktail of choice. 🍹🍸

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