Acute and Critical Care

Original Article

Infection
Methylprednisolone pulse therapy for critically ill patients with COVID-19: a cohort study: Keum-Ju Choi, Soo Kyun Jung, Kyung Chan Kim, Eun Jin Kim; Acute Crit Care. 2023;38(1):57-67. Published online February 7, 2023; DOI: https://doi.org/10.4266/acc.2022.00941; Correction in: Acute Crit Care 2023;38(2):249

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Abstract PDF: Background
The guidelines recommend the use of dexamethasone 6 mg or an equivalent dose in patients with coronavirus disease 2019 (COVID-19) who require supplemental oxygen. Given that the severity of COVID-19 varies, we investigated the effect of a pulse dose of corticosteroids on the clinical course of critically ill patients with COVID-19. Methods: This single-center, retrospective cohort study was conducted between September and December 2021, which was when the Delta variant of the COVID-19 virus was predominant. We evaluated the mortality and oxygenation of severe to critical COVID-19 cases between groups that received dexamethasone 6 mg for 10 days (control group) and methylprednisolone 250 mg/day for 3 days (pulse group). Results: Among 44 patients, 14 and 30 patients were treated with control steroids and pulse steroids, respectively. There was no difference in disease severity, time from COVID-19 diagnosis to steroid administration, or use of remdesivir or antibacterial agents between the two groups. The pulse steroid group showed a significant improvement in oxygenation before and after steroid treatment (P<0.001) compared with the control steroid group (P=0.196). There was no difference in in-hospital mortality (P=0.186); however, the pulse steroid group had a lower mortality rate (23.3%) than the control steroid group (42.9%). There was a significant difference in the length of hospital stay between both two groups (P=0.039). Conclusions: Pulse steroids showed no mortality benefit but were associated with oxygenation improvement and shorter hospital stay than control steroids. Hyperglycemia should be carefully monitored with pulse steroids.

Review Article

Meta-analysis
The efficacy of vitamin C, thiamine, and corticosteroid therapy in adult sepsis patients: a systematic review and meta-analysis: Manoj Kumar Reddy Somagutta, Maria Kezia Lourdes Pormento, Muhammad Adnan Khan, Alaa Hamdan, Namrata Hange, Manish KC, Sukrut Pagad, Molly Sanjay Jain, Sivasthikka Lingarajah, Vishal Sharma, Jaspreet Kaur, Bernard Emuze, Erkan Batti, Obumneme Jude Iloeje; Acute Crit Care. 2021;36(3):185-200. Published online June 30, 2021; DOI: https://doi.org/10.4266/acc.2021.00108

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Previous studies have suggested favorable outcomes of hydrocortisone, ascorbic acid (vitamin C), and thiamine (HAT) therapy in patients with sepsis. However, similar results have not been duplicated in sequential studies. This meta-analysis aimed to reevaluate the value of HAT treatment in patients with sepsis. Electronic databases were searched up until October 2020 for any studies that compared the effect of HAT versus non-HAT use in patients with sepsis. Data from 15 studies (eight randomized controlled trials [RCTs] and seven cohort studies) involving 67,349 patients were included. The results from the RCTs show no significant benefit of triple therapy on hospital mortality (risk ratio [RR], 0.99; P=0.92; I²=0%); intensive care unit (ICU) mortality (RR, 0.77; P=0.20; I²=58%); ICU length of stay (weighted mean difference [WMD], 0.11; P=0.86; I² =37%) or hospital length of stay (WMD: 0.57; P=0.49; I²=17%), and renal replacement therapy (RR, 0.64; P=0.44; I²=39%). The delta Sequential Organ Failure Assessment (SOFA) score favored treatment after a sensitivity analysis (WMD, –0.72; P=0.01; I²=32%). However, a significant effect was noted for the duration of vasopressor use (WMD, –25.49; P<0.001; I²=46%). The results from cohort studies have also shown no significant benefit of HAT therapy on hospital mortality, ICU mortality, ICU length of stay, length of hospital stay, the delta SOFA score, the use of renal replacement therapy, or vasopressor duration. HAT therapy significantly reduced the duration of vasopressor use and improved the SOFA score but appeared not to have significant benefits in other outcomes for patients with sepsis. Further RCTs can help understand its benefit exclusively.

Citations

Citations to this article as recorded by

Effect of intravenous vitamin C on adult septic patients: a systematic review and meta-analysis
Huoyan Liang, Qingqing Mu, Wenju Sun, Liming Liu, Simin Qiu, Zili Xu, Yuqing Cui, Yan Yan, Tongwen Sun
Frontiers in Nutrition.2023;[Epub] CrossRef
Insights Into Thiamine Supplementation in Patients With Septic Shock
Nara Aline Costa, Amanda Gomes Pereira, Clara Sandra Araujo Sugizaki, Nayane Maria Vieira, Leonardo Rufino Garcia, Sérgio Alberto Rupp de Paiva, Leonardo Antonio Mamede Zornoff, Paula Schmidt Azevedo, Bertha Furlan Polegato, Marcos Ferreira Minicucci
Frontiers in Medicine.2022;[Epub] CrossRef
Vitamin C-induced Hemolysis: Meta-summary and Review of Literature
Deven Juneja, Ravi Jain
Indian Journal of Critical Care Medicine.2022; 26(2): 224. CrossRef
Is it time to reconsider the administration of thiamine alone or in combination with vitamin C in critically ill patients? A meta-analysis of clinical trial studies
Nafiseh Shokri-mashhadi, Ali Aliyari, Zahra Hajhashemy, Saeed Saadat, Mohammad Hossein Rouhani
Journal of Intensive Care.2022;[Epub] CrossRef
Parenteral Vitamin C in Patients with Severe Infection: A Systematic Review
Arnav Agarwal, John Basmaji, Shannon M. Fernando, Fang Zhou Ge, Yingqi Xiao, Haseeb Faisal, Kimia Honarmand, Mathieu Hylands, Vincent Lau, Kimberley Lewis, Rachel Couban, François Lamontagne, Neill K. J. Adhikari
NEJM Evidence.2022;[Epub] CrossRef
Unanswered questions on the use of hydrocortisone, ascorbic acid, and thiamine therapy in sepsis and septic shock
David Ragoonanan, Nicolas Tran, Veeshal Modi, Paige Morgan Nickelsen
American Journal of Health-System Pharmacy.2022; 79(19): 1626. CrossRef
Impacts of Corticosteroid Therapy at Acute Stage of Hospital-Onset Clostridioides difficile Infections
Ching-Chi Lee, Jen-Chieh Lee, Chun-Wei Chiu, Pei-Jane Tsai, Wen-Chien Ko, Yuan-Pin Hung
Infection and Drug Resistance.2022; Volume 15: 5387. CrossRef
The impact of vitamin C-containing treatment on the mortality of patients with sepsis: A systematic review and meta-analysis of randomized controlled trials
Ching-Yi Chen, Chien-Tung Chiu, Ho-Sheng Lee, Chih-Cheng Lai
Journal of Infection and Public Health.2022; 15(12): 1514. CrossRef
Role of high dose vitamin C in management of hospitalised COVID-19 patients: A minireview
Deven Juneja, Anish Gupta, Sahil Kataria, Omender Singh
World Journal of Virology.2022; 11(5): 300. CrossRef
Current role of high dose vitamin C in sepsis management: A concise review
Deven Juneja, Prashant Nasa, Ravi Jain
World Journal of Critical Care Medicine.2022; 11(6): 349. CrossRef
HYDROCORTISONE, ASCORBIC ACID, AND THIAMINE THERAPY DECREASE RENAL OXIDATIVE STRESS AND ACUTE KIDNEY INJURY IN MURINE SEPSIS
John Kim, Allan Stolarski, Qiuyang Zhang, Katherine Wee, Daniel Remick
Shock.2022; 58(5): 426. CrossRef
Early administration of Vitamin C in patients with sepsis or septic shock in emergency departments: A multicenter, double blinded, randomized controlled trial: The C-EASIE trial protocol
Stefanie Vandervelden, Lina Wauters, Jan Breuls, Steffen Fieuws, Philippe Vanhove, Ives Hubloue, Magali Bartiaux, Jacques Creteur, François Stifkens, Koen Monsieurs, Didier Desruelles, Elisa Panada
PLOS ONE.2021; 16(11): e0259699. CrossRef
Hydrocortisone, ascorbic acid, and thiamine (HAT) for sepsis and septic shock: a meta-analysis with sequential trial analysis
Weilan Na, Huili Shen, Yichu Li, Dong Qu
Journal of Intensive Care.2021;[Epub] CrossRef

Original Articles

Basic science and research
Prognostic Implication of Adrenocortical Response during the Course of Critical Illness: Jin Hwa Song, Jung Hee Kim, Sang-Min Lee, Jinwoo Lee; Acute Crit Care. 2019;34(1):38-45. Published online January 30, 2019; DOI: https://doi.org/10.4266/acc.2018.00339

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Abstract PDF Supplementary Material

Background
Critical illness-related corticosteroid insufficiency (CIRCI) and adrenocorticotropic hormone (ACTH)-cortisol dissociation are hormonal conditions frequently observed in patients in the intensive care unit (ICU). The aim of this study was to evaluate the association between ACTH-cortisol dissociation and clinical outcomes of critically ill patients. Methods: We retrospectively reviewed the medical records of 94 ICU patients who underwent two rapid cosyntropin tests during hospital admission and compared the clinical aspects of patients with and without ACTH-cortisol dissociation. ACTH-cortisol dissociation was defined as plasma ACTH and serum cortisol concentrations of <22 pmol/L and >600 nmol/L, respectively. Results: Dissociation was present in 30 of the 94 patients (31.9%). Patients with ACTH-cortisol dissociation in the initial test had significantly higher hospital mortality rate than those in the control group (55% vs. 25.7%, P=0.013) There was no difference in hospital mortality between patients classified as having CIRCI and those who were not. In multivariate adjusted Cox regression analysis, the mortality risk was higher in the group with ACTH-cortisol dissociation (hazard ratio, 2.98; 95% confidence interval, 1.34 to 6.63; P=0.007). Patients with dissociation in two consecutive stimulation tests showed the highest hospital mortality rate among groups classified according to stimulation test results (100% vs. 31.3%). Conclusions: The hospital mortality was higher in ICU patients diagnosed with ACTH-cortisol dissociation. It is clinically feasible to evaluate the presence of ACTH-cortisol dissociation by analyzing rapid ACTH stimulation test results in critically ill patients.

Citations

Citations to this article as recorded by

Serum ACTH and Cortisol Level is Associated with the Acute Gastrointestinal Injury Grade in ICU Patients
Wen Xu, Yuzhen Qiu, Hongping Qiu, Ming Zhong, Lei Li
International Journal of General Medicine.2024; Volume 17: 127. CrossRef
PROGNOSTIC VALUE OF LOW-DOSE ADRENOCORTICOTROPIC HORMONE TEST IN CRITICALLY ILL PATIENTS
Ahmad B. Abdelrehim, Fatma M. Mohsen, Mostafa A. Haredi, Zeinab Abdel Hameed, Walaa H. Ibrahim
Shock.2023; 59(6): 871. CrossRef
Copeptin and stress-induced hyperglycemia in critically ill patients: A prospective study
Lilian Rodrigues Henrique, Daisy Crispim, Tarsila Vieceli, Ariell Freires Schaeffer, Priscila Bellaver, Cristiane Bauermann Leitão, Tatiana Helena Rech, Antonio Palazón-Bru
PLOS ONE.2021; 16(4): e0250035. CrossRef
Comparison of salivary and serum cortisol levels in mechanically ventilated patients and non-critically ill patients
Jung Hee Kim, Yoon Ji Kim, Sang-Min Lee, Jinwoo Lee
Acute and Critical Care.2020; 35(3): 149. CrossRef

Infection
Sepsis in Patients Receiving Immunosuppressive Drugs in Korea: Analysis of the National Insurance Database from 2009 to 2013: Seung-Young Oh, Songhee Cho, Hannah Lee, Eun Jin Chang, Se Hee Min, Ho Geol Ryu; Korean J Crit Care Med. 2015;30(4):249-257. Published online November 30, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.4.249

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Abstract PDF

Background
The aim of this study is to evaluate the influence of immunosuppressants on in-hospital mortality from sepsis.
Methods
Using data of the Health Insurance Review & Assessment Service, we collected data from patients who were admitted to the hospital due to sepsis from 2009 to 2013. Based on drugs commonly used for immunosuppression caused by various diseases, patients were divided into three groups; immunosuppressant group, steroid-only group, and control group. Patients with no history of immunosuppressants or steroids were assigned to the control group. To identify risk factors of in-hospital mortality in sepsis, we compared differences in patient characteristics, comorbidities, intensive care unit (ICU) care requirements, and immunodeficiency profiles. Subgroup analysis according to age was also performed.
Results
Of the 185,671 included patients, 13,935 (7.5%) were in the steroid-only group and 2,771 patients (1.5%) were in the immunosuppressant group. The overall in-hospital mortality was 38.9% and showed an increasing trend with age. The steroid-only group showed the lowest in-hospital mortality among the three groups except the patients younger than 30 years. The steroid-only group and immunosuppressant group received ICU treatment more frequently (p < 0.001), stayed longer in the hospital (p < 0.001), and showed higher medical expenditure (p < 0.001) compared to the normal group. Univariate and multivariate analyses revealed that age, male gender, comorbidities (especially malignancy), and ICU treatment had a significant effect on in-hospital mortality.
Conclusions
Despite longer hospital length of stay and more frequent need for ICU care, the in-hospital mortality was lower in patients taking immunosuppressive drugs than in patients not taking immunosuppressive drugs.

Citations

Citations to this article as recorded by

Predictive performance of NEWS and qSOFA in immunocompromised sepsis patients at the emergency department
Lisanne Boekhoud, Helena M. E. A. Schaap, Rick L. Huizinga, Tycho J. Olgers, Jan C. ter Maaten, Douwe F. Postma, Hjalmar R. Bouma
Infection.2024;[Epub] CrossRef
Effects of Early Initiation of High-Dose Dexamethasone Therapy on Pro-Inflammatory Cytokines and Mortality in LPS-Challenged Mice
Ji-young Son, Won Gun Kwack, Eun Kyoung Chung, Sooyoung Shin, Yeo Jin Choi
Healthcare.2022; 10(7): 1247. CrossRef
Alleviation of LPS-Induced Inflammation and Septic Shock by Lactiplantibacillus plantarum K8 Lysates
Gayoung Kim, Kyeong-Hun Choi, Hangeun Kim, Dae-Kyun Chung
International Journal of Molecular Sciences.2021; 22(11): 5921. CrossRef
Critical Care Research Using “Big Data”: A Reality in the Near Future
Kwangha Lee
Acute and Critical Care.2018; 33(4): 269. CrossRef
Should Very Old Patients Be Admitted to the Intensive Care Units?
Jun Kwon Cha, In-Ae Song
The Korean Journal of Critical Care Medicine.2017; 32(4): 376. CrossRef
Sepsis in Immunocompromised Patients: Current Status in Korea
Kwangha Lee
The Korean Journal of Critical Care Medicine.2015; 30(4): 239. CrossRef

Case Report

A Case of Peripheral T Cell Lymphoma Presenting as Severe Hypoxic Respiratory Failure: A Case Report: Joon Seok Choi, Hong Joon Shin, Eun Young Kim, In Jae Oh, Kyu Sik Kim, Yu Il Kim, Sung Chul Lim, Young Chul Kim, Yoo Duk Choi, Hyun Ju Seon, Yong Soo Kwon; Korean J Crit Care Med. 2010;25(1):43-47.; DOI: https://doi.org/10.4266/kjccm.2010.25.1.43

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Abstract PDF: We describe here the first known case in Korea of pulmonary involvement with peripheral T cell lymphoma and the patient presented with severe hypoxic respiratory failure. A 57-yr-old man was admitted to our hospital with rapid progression of dyspnea and bilateral diffuse infiltration on a chest radiograph. He received mechanical ventilation and low dose corticosteroid treatment under the suspicion of critical illness-related corticosteroid insufficiency. Transbronchial lung biopsy revealed large atypical lymphoid cells with positivity for CD3+. We diagnosed this patient as having a peripheral T cell lymphoma and we treated him with high dose corticosteroid. His clinical and radiologic findings rapidly improved and then he received a full dose of chemotherapy for the peripheral T cell lymphoma.

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