Adjuvant treatments in sepsis

Q: All of the following have shown some adjuvant benefit in septic shock except?

A) Vitamin C 
B) Thiamine 
C) Hydrocortisone 
D) Ibuprofen 
E) Esmolol


Answer: D

High burden of sepsis mortality has constantly geared investigators to look into alternate and adjuvant treatments for septic shock. Over the last five decades, the laundry list of such treatment has grown so long that can't be described here. 

NSAIDs (Non-steroidal Anti Inflammatory Drugs) as the name suggests have generated a lot of interest due to anti-inflammatory properties, but they failed to show any benefit in septic shock. 1

Interestingly, short-acting beta blocker (Esmolol) has shown benefit, probably due to attenuate the deleterious effects of the sympathetic adrenergic response (choice E).2, 3

Debate on the use of stress dose steroid in septic shock is never-ending but literature tends to lean towards some benefit, particularly in septic shock state unresponsive to resuscitation and pressor (choice C). 5

Thiamine and Vitamin C are relatively new on the horizon but have shown benefit in combination with steroid (Choices A and B). 4, 5, 6

#sepsis
#hemodynamics



References:

1. Bernard GR, Wheeler AP, Russell JA, et al. The effects of ibuprofen on the physiology and survival of patients with sepsis. The Ibuprofen in Sepsis Study Group. N Engl J Med 1997; 336:912.

2. Morelli A, Ertmer C, Westphal M, et al. Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial. JAMA 2013; 310:1683. 

3. Liu P, Wu Q, Tang Y, et al. The influence of esmolol on septic shock and sepsis: A meta-analysis of randomized controlled studies. Am J Emerg Med 2018; 36:470.

4. Mallat J, Lemyze M, Thevenin D. Do not forget to give thiamine to your septic shock patient! Journal of Thoracic Disease. 2016;8(6):1062-1066. 

5. Marik PE, Khangoora V, Rivera R, et al. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest 2017; 151:1229. 

6. Woolum JA, Abner EL, Kelly A, Thompson Bastin ML, Morris PE, Flannery AH. Effect of Thiamine Administration on Lactate Clearance and Mortality in Patients With Septic Shock. Crit Care Med. 2018 Jul 18. [Epub ahead of print]