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Background: Noninvasive ventilation (NIV) is an established first-line treatment of acute respiratory failure both in emergency departments (ED) and intensive care unit (ICU) settings. It is however not always successful. Materials and methods: Prospective, observational study was done among patients above 18 years presenting with acute respiratory failure initiated on NIV. Patients were placed in one of two groups covering successful NIV treatment and NIV failure. Two groups were compared on four variables: initial respiratory rate (RR), initial high-sensitivity C-reactive protein (hs-CRP), PaO2/FiO2 ratio (p/f ratio), and heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) score at the end of 1 hour of initiation of NIV. Results: A total of 104 patients fulfilling the inclusion criteria were included in the study, of which 55 (52.88%) were exclusively treated with NIV (NIV success group), and 49 (47.11%) required endotracheal intubation and mechanical ventilation (NIV failure group). Noninvasive ventilation failure group had a higher mean initial RR compared with NIV success group (40.65 ± 3.88 vs 31.98 ± 3.15, p <0.001). Mean initial PaO2/FiO2 ratio was also significantly lower in the NIV failure group (184.57 ± 50.33 vs 277.29 ± 34.70, p <0.001). Odds ratio for successful NIV treatment with a high initial RR was 0.503 (95% confidence interval (CI), 0.390-0.649) and with a higher initial PaO2/FiO2 ratio was 1.053 (95% CI: 1.032-1.071 and with a HACOR score of >5 at the end of 1 hour of initiation of NIV was highly associated with NIV failure (p <0.001). A high initial level of hs-CRP was 0.949 (95% CI: 0.927-0.970). Conclusion: Noninvasive ventilation failure could be predicted with information available at presentation in ED, and unnecessary delay in endotracheal intubation could possibly be prevented. How to cite this article: Mathen PG, Kumar KPG, Mohan N, Sreekrishnan TP, Nair SB, Krishnan AK, et al. Prediction of Noninvasive Ventilation Failure in a Mixed Population Visiting the Emergency Department in a Tertiary Care Center in India. Indian J Crit Care Med 2022;26(10):1115-1119.
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BACKGROUND: Sepsis remains a leading cause of death worldwide despite advances in management strategies. Preclinical and observational studies have found mortality benefit with high-dose vitamin C in sepsis. Our study aims to prospectively evaluate the effect of intravenous hydrocortisone, vitamin C [ascorbic acid (AA)], and thiamine (HAT) administration in reducing inpatient all-cause mortality among patients with septic shock. MATERIALS AND METHODS: Our single-center, prospective, open-label, randomized controlled trial recruited patients with admitting diagnosis of septic shock and assigned eligible patients (1:1) into either intervention (HAT) or control group (routine). The HAT group received intravenous combination of vitamin C (1.5 g every 6 hours), thiamine (200 mg every 12 hours), and hydrocortisone (50 mg every 6 hours) within 6 hours of onset of septic shock admission. The treatment was continued for at least 4 days, in addition to the routine standard of care provided to the control group. Thiamine and hydrocortisone use in control arm was not restricted. Vitamin C levels were estimated at baseline and at the end of the 4 days of treatment for both groups. The primary outcome evaluated was mortality during inpatient stay. RESULTS: Among 90 patients enrolled, 88 patients completed the study protocol. The baseline characteristics between the HAT (n = 45) and the routine (n = 43) groups were comparable. The all-cause mortality in the HAT cohort was 57% (26/45) compared to 53% (23/43) in the routine care group (p = 0.4, OR 1.19, 95% CI 0.51-2.76). The time to reversal of septic shock was significantly lower in the HAT (34.58 ± 22.63 hours) in comparison to the routine care (45.42 ± 24.4 hours) (p = 0.03, mean difference -10.84, 95% CI -20.8 to -0.87). No significant difference was observed between the HAT and the routine care with respect to changes in sequential organ failure assessment (SOFA) scores at 72 hours (2.23 ± 2.4 vs 1.38 ± 3.1), the use of mechanical ventilation (48% vs 46%), and mean Vasoactive Inotropic Score (7.77 ± 12.12 vs 8.86 ± 12.5). CONCLUSION: Intravenous administration of vitamin C, thiamine, and hydrocortisone did not significantly improve the inpatient all-cause mortality among patients with septic shock. CLINICAL SIGNIFICANCE: HAT protocol does not reduce hospital mortality but decreases time to shock reversal in septic shock. HOW TO CITE THIS ARTICLE: Mohamed ZU, Prasannan P, Moni M, Edathadathil F, Prasanna P, Menon A, et al. Vitamin C Therapy for Routine Care in Septic Shock (ViCTOR) Trial: Effect of Intravenous Vitamin C, Thiamine, and Hydrocortisone Administration on Inpatient Mortality among Patients with Septic Shock. Indian J Crit Care Med 2020;24(8):653-661.