In this episode I’ll:
1. Discuss an article about thiamine in patients with septic shock.
2. Answer the drug information question “Why is the dose of adenosine reduced when given through a central line?”
3. Share a tip for responding to inpatient medical emergencies.
Article
Effect of Thiamine Administration on Lactate Clearance and Mortality in Patients With Septic Shock
Lead author: Jordan Woolum
Published in Critical Care Medicine July 2018
Background
In a small randomized controlled trial from 2016, thiamine appeared to improve lactate clearance and reduce mortality in patients with septic shock and laboratory-confirmed thiamine deficiency. The authors of this current study sought to test the hypothesis that critically ill patients with septic shock exposed to thiamine would demonstrate improved lactate clearance and more favorable clinical outcomes compared with those not receiving thiamine.
Methods
The study was a retrospective, single-center, matched cohort study in a tertiary care academic medical center. Patients in the medical or surgical ICU with a diagnosis of septic shock were included in the study. The primary objective was to determine if thiamine administration was associated with a reduced time to lactate clearance in septic shock. Secondary outcomes included 28-day mortality, acute kidney injury, and need for renal replacement therapy, and vasopressor and mechanical ventilation-free days.
Results
123 thiamine-treated patients were matched with 246 patients who did not receive thiamine. Treatment with thiamine was associated with an improved likelihood of lactate clearance (hazard ratio, 1.3). In addition, thiamine administration was associated with a reduction in 28-day mortality (hazard ratio, 0.67). Both of these hazard ratios were statistically significant. There were no differences in any other pre-specified outcomes.
Conclusion
The authors concluded:
Thiamine administration within 24 hours of admission in patients presenting with septic shock was associated with improved lactate clearance and a reduction in 28-day mortality compared with matched controls.
Discussion
While the dose of thiamine was variable, about 2/3 of the patients received a thiamine dose of 500 mg IV three times per day. As IV thiamine is safe and inexpensive, this is an exciting development deserving of further prospective study. One interesting aspect of this study is to think about it in context with the “Marik Protocol” of vitamin C, hydrocortisone, and thiamine. This study, which I reviewed in episode 177, used 200 mg twice daily of IV thiamine. It too was a retrospective study. The interesting part is that thiamine was included almost as an afterthought, to prevent theoretical toxicity from the vitamin C used in the protocol. Whether patients had laboratory-confirmed thiamine deficiency in the Marik study was not reported. It is possible that the inclusion of thiamine in this protocol is responsible for a significant part of any mortality benefit that may arise from the combination. Hopefully future studies of vitamin C, thiamine, and hydrocortisone will include baseline thiamine levels.
Drug information question
Q: Why is the adenosine dose reduced by 50% when it is given in a central line?
A: This practice originates from a 1993 dose-finding safety and efficacy study for adenosine which compared doses of 3, 6, 9, and 12 mg in peripheral and central lines. In the peripheral line group, tachycardia was terminated in 70% of patients who got 6 or less mg of adenosine. In the central line group, tachycardia was terminated in 70% of patients who got 3 mg of adenosine. In this study, there was no difference between the two routes of drug administration in the incidence of side effects or transient arrhythmias at the time of tachycardia termination. However, there have been subsequent case reports of bradycardia and severe side effects in patients who received larger doses of adenosine via a central line.
Tip for responding to inpatient medical emergencies
Provide medications to the nurse in the most ready to administer form. For IV infusions, this means priming IV tubing and labeling the lines.
For IV push medications, this means giving the nurse a primed saline flush and an alcohol swab along with a labeled syringe of the medications.
When you provide medications in a ready to use form, instead of just providing an unopened vial, you shorten the lag time from when the medication is needed to when it is actually administered.
In the Hospital Pharmacy Academy, I provide more in-depth training and support for pharmacists that wish to learn how to respond to code blue and rapid response calls with my “Learn Code Response Blueprint.”
The Learn Code Response Blueprint is a series of video trainings that teach Code Response Basics, Airway Pharmacology, Septic Shock Management, Patient Assessment, and ECG Recognition for Pharmacists. To sign up go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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