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VITAMINS for Kids – Hydrocortisone, Ascorbic Acid, and Thiamine for Children with Septic Shock

February 6, 2020

Written by Clay Smith

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There may be mortality benefit with use of hydrocortisone, ascorbic acid, and thiamine (HAT) therapy in critically ill children. However, in light of the recent VITAMINS RCT, this is suspect.

Why does this matter?
With the publication of VITAMINS, previous small case series in adults are being called into question. What about HAT for children?

Is this a HAT trick?
This was a retrospective study with propensity score matching over a roughly 5 year period, including 557 children with septic shock. In the propensity matched cohorts, when considering 43 matched controls to 43 patients receiving HAT therapy, 30-day mortality was 28% vs 9%, p=0.03. HAT had no impact on other measures, such as vasopressor-free days or hospital-free days. There was no difference in mortality between unmatched, untreated controls and HAT treated patients. This, like prior HAT studies, is interesting and hypothesis generating. However, even with propensity matching, there is no accounting for all the possible confounders. When randomized, as in the VITAMINS trial, there was no difference. It seems HAT therapy may be too good to be true. That has now been proven in adults, and I wonder if a randomized trial in children would be similar.

Hydrocortisone-Ascorbic Acid-Thiamine Use Associated with Lower Mortality in Pediatric Septic Shock. Am J Respir Crit Care Med. 2020 Jan 9. doi: 10.1164/rccm.201908-1543LE. [Epub ahead of print]

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What are your thoughts?