Neurological disturbances and hyperdynamic shock in a patient with esophagocoloplasty

Randomized, Double-Blind, Placebo-Controlled Trial of Thiamine as a Metabolic Resuscitator in Septic Shock: A Pilot Study

OBJECTIVE

To determine if intravenous thiamine would reduce lactate in patients with septic shock.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Two US hospitals.

PATIENTS

Adult patients with septic shock and elevated (> 3 mmol/L) lactate between 2010 and 2014.

INTERVENTIONS

Thiamine 200 mg or matching placebo twice daily for 7 days or until hospital discharge.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was lactate levels 24 hours after the first study dose. Of 715 patients meeting the inclusion criteria, 88 patients were enrolled and received study drug. There was no difference in the primary outcome of lactate levels at 24 hours after study start between the thiamine and placebo groups (median: 2.5 mmol/L [1.5, 3.4] vs. 2.6 mmol/L [1.6, 5.1], p = 0.40). There was no difference in secondary outcomes including time to shock reversal, severity of illness and mortality. 35% of the patients were thiamine deficient at baseline. In this predefined subgroup, those in the thiamine treatment group had statistically significantly lower lactate levels at 24 hours (median 2.1 mmol/L [1.4, 2.5] vs. 3.1 [1.9, 8.3], p = 0.03). There was a statistically significant decrease in mortality over time in those receiving thiamine in this subgroup (p = 0.047).

CONCLUSION

Administration of thiamine did not improve lactate levels or other outcomes in the overall group of patients with septic shock and elevated lactate. In those with baseline thiamine deficiency, patients in the thiamine group had significantly lower lactate levels at 24 hours and a possible decrease in mortality over time.

Retrosternal revision of jejunum interposed in the anterior sternal space for the treatment of esophageal atresia

Esophageal replacement continues to be a challenging operation associated with significant morbidity. We report the case of a 5-year-old boy with esophageal atresia treated by jejunal interposition in the anterior sternal space who had revision of the interposed jejunum into the retrosternal space for cosmetic reasons.