Thiamine for Renal Protection in Septic Shock (TRPSS): A Randomized, Placebo-controlled, Clinical Trial

The Impact of Extended-Hours Patient Recruitment on Critical Care Clinical Trial Enrollment

IMPORTANCE

Patient recruitment is a critical factor in running successful and timely clinical trials in the critical care field where the timing of presentation of patients is difficult to predict and the study interventions are often time sensitive.

OBJECTIVES

The goal of this study was to analyze the timing of patient enrollments from previous clinical trials to identify patterns and assess the impact of providing extended-hours coverage on patient enrollment.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective cohort study at a tertiary academic hospital in the United States between 2016 and 2024 on patients who were enrolled in five recent critical care clinical trials.

MAIN OUTCOMES AND MEASURES

We reviewed the patient enrollment data. We quantified the number of enrollments during business hours (9 am-5 pm) compared with outside of business hours and analyzed the frequency of enrollment by day of the week and time of day.

RESULTS

There were 352 patients enrolled between 2016 and 2024 across five clinical trials. A total of 242 patients (68.8%) were enrolled outside of business hours. 72.4% of patients were enrolled during weekdays and 27.6% during weekends. The enrollment pattern did not differ significantly across days of the week, ranging from 45 (12.8%) on Friday to 56 (15.9%) on Thursday. Enrollment from 2 pm to 10 pm accounted for more than 50% of the total enrollments. Recruiting only during business hours would have resulted in an additional 15 years to complete one of the trials.

CONCLUSIONS AND RELEVANCE

A review of our five recent critical care trials showed that nearly 70% of enrollment occurred outside of business hours. Limiting recruitment to only business hours would have resulted in a prohibitively longer time to complete the trials. This analysis provides a strong motivation and rationale for extending research staffing coverage beyond business hours.

Thiamine and Ascorbic Acid in Sepsis and Septic Shock: A Review of Evidence for their Role in Practice

Objective

To evaluate the evidence for the use of ascorbic acid, thiamine, or a combination of both agents without corticosteroids in the management of sepsis and septic shock.

Data Sources

A review of the literature was conducted through August 2023 on PubMed, MEDLINE, Web of Science, and CINAHL using the following terminology: "ascorbic acid" OR "vitamin C" OR "thiamine" OR "vitamin B" OR "vitamin B 1" AND "sepsis" OR "septic shock" NOT "steroid" OR "hydrocortisone" OR "corticosteroid."

Study Selection and Data Extraction

Trials that described patient outcomes, medication efficacy, and medication safety data were considered for inclusion, while reports describing the use of either or both thiamine and ascorbic acid for a non-sepsis indication and reports that were not readily translatable to English were excluded. Studies that allowed corticosteroid use in both the intervention and control cohorts as part of a standard-of-care protocol were eligible for inclusion.

Data Synthesis

Heterogeneity of data exists, marked by divergent quantifications for successful pharmacotherapy interventions. Whereas some data support changes in patient outcome scores or critical illness indices, others have failed to demonstrate any meaningful benefit to ICU length of stay, ventilator status, or mortality.

Conclusion

Exploring the individual and synergistic effects of ascorbic acid and thiamine on key pathways implicated in sepsis pathophysiology has not yielded unequivocal evidence supporting their use without concomitant corticosteroids.

Association between 24-hour urine volume and 28-day intensive care unit mortality in sepsis patients: a multi-center retrospective cohort study

Background

Sepsis is defined as a dysregulated host response to infection that results in life-threatening organ dysfunction. The 24-hour urine volume plays a crucial role in assessing the prognosis of septic patients. This study aims to investigate the relationship between 24-hour urine volume and 28-day intensive care unit (ICU) mortality in septic patients and exploring the dose-response relationship between these variables.

Methods

This retrospective cohort study analyzed data from 7,218 sepsis patients in the eICU Collaborative Research Database. Logistic regression models and generalized additive models were used to examine the relationship between 24-hour urine volume and 28-day ICU mortality.

Results

A negative correlation was found between 24-hour urine volume and ICU 28-day mortality. In the fully adjusted model, each 50 mL increase in 24-hour urine volume significantly reduced mortality risk by 1% (OR = 0.99, 95% CI = 0.98-0.99, P < 0.001). A nonlinear dose-response relationship was observed, with an inflection point at ~1,663.5 ml. Below this threshold, increased urine volume was significantly associated with reduced mortality risk (OR = 0.97, 95% CI: 0.96-0.98, P < 0.001), while above this point, the relationship was not statistically significant.

Conclusion

This study demonstrates a non-linear negative correlation between 24-hour urine volume and 28-day ICU mortality in sepsis patients.

New randomized controlled trials on micronutrients in critical care nutrition: A narrative review

There has been increasing interest in the role of micronutrient supplementation in critical care. This narrative review summarizes the recent studies on micronutrients in critically ill patients. We searched two databases for primary randomized controlled trials that investigated the effects of micronutrient supplementation in patients with critical illness published from January 2021 to August 2023. Personal files, reference lists of included studies, and previous reviews were also screened. Twelve studies reported on vitamin C, four studies on vitamin D, three studies on thiamin, two studies on multivitamins, and one study on cobalamin. The therapeutic effects of vitamin C appear mixed, although vitamin C monotherapy appears more promising than vitamin C combination therapy. Intramuscular administration of vitamin D appeared to lower mortality, mechanical ventilation duration, and intensive care unit stay, whereas enteral administration showed limited clinical benefits. Intravenous thiamin was not associated with improved outcomes in patients with septic shock or hypophosphatemia. Preliminary evidence suggests reduced vasopressor dose with cobalamin. Decreased disease severity and hospital stay in patients with COVID-19 with vitamins A-E requires further investigation, whereas providing solely B-group vitamins did not demonstrate therapeutic effects. It is currently premature to endorse the provision of high-dose micronutrients in critical illness to improve clinical outcomes. This review may help to inform the design of future trials that will help better elucidate the optimal dosage and form of micronutrients, methods of administration, and subgroups of patients with critical illness who may most benefit.

Artificial intelligence and machine learning's role in sepsis-associated acute kidney injury

Sepsis-associated acute kidney injury (SA-AKI) is a serious complication in critically ill patients, resulting in higher mortality, morbidity, and cost. The intricate pathophysiology of SA-AKI requires vigilant clinical monitoring and appropriate, prompt intervention. While traditional statistical analyses have identified severe risk factors for SA-AKI, the results have been inconsistent across studies. This has led to growing interest in leveraging artificial intelligence (AI) and machine learning (ML) to predict SA-AKI better. ML can uncover complex patterns beyond human discernment by analyzing vast datasets. Supervised learning models like XGBoost and RNN-LSTM have proven remarkably accurate at predicting SA-AKI onset and subsequent mortality, often surpassing traditional risk scores. Meanwhile, unsupervised learning reveals clinically relevant sub-phenotypes among diverse SA-AKI patients, enabling more tailored care. In addition, it potentially optimizes sepsis treatment to prevent SA-AKI through continual refinement based on patient outcomes. However, utilizing AI/ML presents ethical and practical challenges regarding data privacy, algorithmic biases, and regulatory compliance. AI/ML allows early risk detection, personalized management, optimal treatment strategies, and collaborative learning for SA-AKI management. Future directions include real-time patient monitoring, simulated data generation, and predictive algorithms for timely interventions. However, a smooth transition to clinical practice demands continuous model enhancements and rigorous regulatory oversight. In this article, we outlined the conventional methods used to address SA-AKI and explore how AI and ML can be applied to diagnose and manage SA-AKI, highlighting their potential to revolutionize SA-AKI care.

Metabolic failure due to thiamine deficiency during critical illness

PURPOSE OF REVIEW

Thiamine is a crucial component in cellular energy metabolism, serving as a cofactor for multiple enzymatic processes and also having a role in regulating neuronal and neuromuscular transmission. Also it exerts antioxidant proprieties. The objective of this review is to consolidate and assess the most recent research concerning the consequences of insufficient thiamine levels for critically ill patients and to examine thiamine-related interventions.

RECENT FINDINGS

Recent studies have unveiled a noteworthy association between thiamine deficiency and unfavorable consequences, such as heightened morbidity and fatality rates. The aforementioned deficiency exhibits a significant presence in medical situations such as starvation and alcohol use disorder, but also in patients during critical illness. Thiamine deficiency can have significant metabolic implications resulting in compromised energy generation and organ dysfunction, warranting prompt recognition and management.

SUMMARY

Thiamine deficiency may not be recognized in critical care. Timely identification and management are imperative to mitigate adverse outcomes and improve patient prognosis. Thiamine may offer benefits for specific patient groups at higher risk of deficiency. Future studies should focus to establish optimal dosing, timing, and monitoring strategies on understanding the pathophysiological changes associated with thiamine deficiency in ICU patients and clarify its role in improving clinical outcomes.

Thiamine administration in septic shock: a post hoc analysis of two randomized trials

BACKGROUND

This is a post hoc analysis of combined cohorts from two previous Phase II clinical trials to assess the effect of thiamine administration on kidney protection and mortality in patients with septic shock.

METHODS

Patient-level data from the Thiamine in Septic Shock Trial (NCT01070810) and the Thiamine for Renal Protection in Septic Shock Trial (NCT03550794) were combined in this analysis. The primary outcome for the current study was survival without the receipt of renal replacement therapy (RRT). Analyses were performed on the overall cohort and the thiamine-deficient cohort (thiamine < 8 nmol/L).

RESULTS

Totally, 158 patients were included. Overall, thiamine administration was associated with higher odds of being alive and RRT-free (adjusted odds ratio [aOR]: 2.05 [95% confidence interval (CI) 1.08-3.90]) and not needing RRT (aOR: 2.59 [95% CI 1.01-6.62]). In the thiamine-deficient group, thiamine administration was associated with higher odds of being alive and RRT-free (aOR: 8.17 [95% CI 1.79-37.22]) and surviving to hospital discharge (aOR: 6.84 [95% CI 1.54-30.36]). There was a significant effect modification by baseline thiamine deficiency for alive and RRT-free (interaction, p = 0.016) and surviving to hospital discharge (p = 0.019).

CONCLUSION

In the combined analysis of two previous randomized trials, thiamine administration was associated with higher odds of being alive and RRT-free at hospital discharge in patients with septic shock. This signal was stronger in patients with thiamine deficiency.