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Raman S, Gibbons KS, Jayashree M, Lalitha AV, Bellomo R, Blythe R, Buckley D, Butt W, Cho HJ, Cree M, de Souza DC, Erickson S, Festa M, Ganu S, George S, James EJ, Johnson K, Le Marsney R, Lister P, Pham TMT, Singh P, Venkatesh B, Wall R, Long DA, Schlapbach LJ. Resuscitation in Paediatric Septic Shock Using Vitamin C and Hydrocortisone (RESPOND): The RESPOND Randomized Controlled Trial Protocol. Pediatr Crit Care Med 2024:00130478-990000000-00421. [PMID: 39724024 DOI: 10.1097/pcc.0000000000003674] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2024]
Abstract
OBJECTIVES Pediatric sepsis results in significant morbidity and mortality worldwide. There is an urgent need to investigate adjunctive therapies that can be administered early. We hypothesize that using vitamin C combined with hydrocortisone increases survival free of inotropes/vasopressors support until day 7 compared with standard care. Here we describe the Resuscitation in Paediatric Septic Shock using Vitamin C and Hydrocortisone (RESPOND) trial protocol, which aims to address this hypothesis. DESIGN Randomized, open label, controlled, parallel-group, three-arm trial with integrated economic evaluation. SETTING Nine Australia and New Zealand PICUs, with interest from additional international sites. PATIENTS Children between 7 days and younger than 18 years old who are treated for suspected or confirmed sepsis and receiving inotropes/vasopressors for greater than 1 hour. INTERVENTIONS IV vitamin C (100 mg/kg [maximum 5 g] every 6 hr) and hydrocortisone (1 mg/kg [maximum 50 mg] every 6 hr), or IV hydrocortisone alone (1 mg/kg [maximum 50 mg] every 6 hr) or standard care. MEASUREMENTS AND MAIN RESULTS Three hundred eighty-four children will be randomly assigned to receive the interventions, or standard care in a 1:1:1 ratio with stratification by steroid administration pre-randomization and hospital site. The primary outcome is time alive and free of inotropes/vasopressors, censored at 7 days. Secondary outcomes include 28-day mortality, survival free of organ support, PICU length of stay, quality of life, functional status and neurodevelopmental vulnerability at 6 months post-enrollment, and hospitalization-related costs. Statistical analysis will be based on an intention-to-treat principle. The study has ethical approval (HREC/20/QCHQ/69922, dated December 21, 2020), is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12621000247875), commenced recruitment on December 8, 2021, and is expected to finish recruitment by mid-2026. CONCLUSIONS Dissemination of the results will occur through publication in peer-reviewed journals, presentations at international conferences, and additional consumer-informed pathways.
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Affiliation(s)
- Sainath Raman
- Children's Intensive Care Research Program, Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Kristen S Gibbons
- Children's Intensive Care Research Program, Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Muralidharan Jayashree
- Pediatric Critical Care Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - A V Lalitha
- Paediatric Intensive Care Unit, St. John's Medical College, Bangalore, India
| | - Rinaldo Bellomo
- Austin Health, Melbourne, VIC, Australia
- Intensive Care Unit, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Robin Blythe
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - David Buckley
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
| | - Warwick Butt
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Hwa Jin Cho
- Paediatric Intensive Care Unit, Department of Pediatrics, Chonnam National University Children's Hospital and Medical school, Gwangju, Korea
| | - Michele Cree
- Department of Pharmacy, Queensland Children's Hospital, South Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Daniela C de Souza
- Paediatric Intensive Care Unit, Hospital Universitário da Universidade de São Paulo, Sao Paolo, Brazil
| | - Simon Erickson
- Paediatric Intensive Care Unit, Perth Children's Hospital, Perth, WA, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, Westmead Children's Hospital, Sydney, NSW, Australia
| | - Subodh Ganu
- Paediatric Intensive Care Unit, Women's and Children's Hospital, Adelaide, SA, Australia
| | - Shane George
- Paediatric Critical Care Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Ebor Jacob James
- Paediatric Intensive Care Unit, Christian Medical College (CMC), Vellore, India
| | - Kerry Johnson
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Renate Le Marsney
- Children's Intensive Care Research Program, Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Paula Lister
- Children's Intensive Care Research Program, Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Critical Care Unit, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Southport, QLD, Australia
| | - Trang M T Pham
- Children's Intensive Care Research Program, Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Puneet Singh
- Paediatric Intensive Care Unit, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Balasubramanian Venkatesh
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Renee Wall
- Consumer Representative, Brisbane, QLD, Australia
| | - Debbie A Long
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Luregn J Schlapbach
- Children's Intensive Care Research Program, Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
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Schlapbach LJ, Raman S, Buckley D, George S, King M, Ridolfi R, Harley A, Cree M, Long D, Erickson S, Singh P, Festa M, Gibbons K, Bellomo R. Resuscitation With Vitamin C, Hydrocortisone, and Thiamin in Children With Septic Shock: A Multicenter Randomized Pilot Study. Pediatr Crit Care Med 2024; 25:159-170. [PMID: 38240537 PMCID: PMC10793796 DOI: 10.1097/pcc.0000000000003346] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Adjunctive therapy with vitamin C, hydrocortisone, and thiamin has been evaluated in adults, but randomized controlled trial (RCT) data in children are lacking. We aimed to test the feasibility of vitamin C, hydrocortisone, and thiamin in PICU patients with septic shock; and to explore whether the intervention is associated with increased survival free of organ dysfunction. DESIGN Open-label parallel, pilot RCT multicenter study. The primary endpoint was feasibility. Clinical endpoints included survival free of organ dysfunction censored at 28 days and nine secondary outcomes, shock reversal, and two proxy measures of intervention efficacy. SETTING Six PICUs in Australia and New Zealand. PATIENTS Children of age between 28 days and 18 years requiring vasoactive drugs for septic shock between August 2019 and March 2021. INTERVENTIONS Patients were assigned 1:1 to receive 1 mg/kg hydrocortisone every 6 hours (q6h), 30 mg/kg ascorbic acid q6h, and 4 mg/kg thiamin every 12 hours (n = 27), or standard septic shock management (n = 33). MEASUREMENTS AND MAIN RESULTS Sixty of 77 (78%) eligible patients consented with 91% of approached parents providing consent. The median time from randomization to intervention was 44 (interquartile range [IQR] 29-120) min. Seventy of seventy-seven (28%) patients had received IV steroids before randomization. Median survival alive and free of organ dysfunction was 20.0 (0.0-26.0) days in the intervention and 21.0 (0.0-25.0) days in the standard care group. Median PICU length of stay was 5.3 (2.5-11.3) days in the intervention group versus 6.9 (3.0-11.5) days in the control group. Shock reversal occurred at a median of 35.2 (14.6-101.2) hours in the intervention group versus 47.3 (22.4-106.8) hours in the standard care group (median difference -12 hr; 95% CI, -56.8 to 32.7 hr). CONCLUSIONS In children requiring vasopressors for septic shock, a protocol comparing adjunctive treatment with high-dose vitamin C, hydrocortisone, and thiamin versus standard care was feasible. These findings assist in making modifications to the trial protocol to enable a better-designed larger RCT.
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Affiliation(s)
- Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Paediatric Critical Care Unit, Perth Children`s Hospital, Perth, WA, Australia
- Paediatric Intensive Care Unit, Sydney Children's Hospital, Sydney, NSW, Australia
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children's Hospitals Network, Sydney, NSW, Australia
- Intensive Care Research, Austin Hospital and Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne., Melbourne, VIC, Australia
- Australian and New Zealand Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Sainath Raman
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - David Buckley
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
| | - Shane George
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Megan King
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia
| | - Roberta Ridolfi
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Amanda Harley
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, QLD, Australia
| | - Michele Cree
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Debbie Long
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Simon Erickson
- Paediatric Critical Care Unit, Perth Children`s Hospital, Perth, WA, Australia
| | - Puneet Singh
- Paediatric Intensive Care Unit, Sydney Children's Hospital, Sydney, NSW, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children's Hospitals Network, Sydney, NSW, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Rinaldo Bellomo
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Paediatric Critical Care Unit, Perth Children`s Hospital, Perth, WA, Australia
- Paediatric Intensive Care Unit, Sydney Children's Hospital, Sydney, NSW, Australia
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children's Hospitals Network, Sydney, NSW, Australia
- Intensive Care Research, Austin Hospital and Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne., Melbourne, VIC, Australia
- Australian and New Zealand Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
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