Critical Care Topics: Vitamin C in Sepsis, Early Basal SQ Insulin in DKA and Early Norepinephrine in Sepsis

This month JC will be reviewing a few critical care topics that are clinically relevant to the practice of EM. First, there has been much interest in the use of ascorbic acid, thiamine and steroids in the management of sepsis. The VICTAS trial was recently closed with EVMS as one of 43 participating sites and is awaiting publication. Our own Drs. Marik and Hooper have published data suggesting efficacy and we will look at a recent RCT regarding the use of vitamin C in patients with sepsis and severe respiratory failure. Second, there have been multiple observational trials showing an association between early vasopressor use and improved outcomes when using norepinephrine early in septic shock resuscitation. A recently published RCT on the topic will be presented that may provide evidence to support this observational data. Finally, another area of interest is whether transitioning DKA patients with early use of SQ home dose basal insulin is associated with better outcomes. Most ED clinicians wait until the patient’s anion gap has closed prior to initiating long acting insulin. In the current climate of ED boarding of ICU patients is there sufficient evidence to support earlier use of long-acting SQ insulin with the potential for improving patient centered outcomes such as ICU admission or ED discharge rates?

Fowler AA et al, Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial JAMA. 2019 Oct 1;322(13):1261-1270. APPRAISAL

Permpikul C, et al, Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med. 2019 May 1;199(9):1097-1105. APPRAISAL

Rappaport SH et al, A Retrospective Study of Early vs Delayed Home Dose Basal Insulin in the Acute Management of Diabetic Ketoacidosis. J Endocr Soc. 2019 Apr 11;3(5):1079-1086 APPRAISAL