Weird Sepsis Cocktail - Vitamin C, Thiamine, Hydrocortisone

Is this real?
This small, single-center before and after trial of IV vitamin C, IV hydrocortisone, and IV thiamine vs control in patients with severe sepsis or septic shock showed markedly decreased mortality in the treatment group, 8.5% vs. 40.4%.  The obvious problem with this study is its small size (47 per group), retrospective before/after design, and single-center study cohort.  Also, I am concerned about the lack of consent for the patients treated under this protocol.  Although it is interesting, and the apparent treatment effect quite pronounced, I'm hesitant to recommend its use in routine practice until it is more rigorously and prospectively evaluated.  In fact, I passed on covering this article in its early release because I try to cover articles which may impact current practice.  However, the FOAM world had blown up with coverage of this small study, so I thought I should give it a look.  And as I read the reviews, my initial impulse to ignore this study started to erode a little.  This is interesting to say the least.  See the curated FOAM resources below.

Spoon Feed
A cocktail of IV vitamin C, hydrocortisone, and thiamine appeared to dramatically reduce mortality in this small, exploratory, before/after study.

Another Spoonful

  • PulmCrit has a great review, with scientific rationale for this and a word from Dr. Marik, lead author.  And EMCrit also has a brand new feature piece published July 16 written by Dr. Marik.
  • REBEL EM unpacks an excellent play-by-play of the article by Haney Mallemat that urges caution.
  • The Skeptics Guide to EM is, understandably, skeptical and has the best quote, "The plural form of anecdote is not data."  They line up more FOAM links and a dozen skeptics to weigh in on it.
  • Ryan Radecki from EM Lit of Note isn't on board yet either.
  • NPR interviews several skeptics in their expose.

Source
Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study.  Chest. 2017 Jun;151(6):1229-1238. doi: 10.1016/j.chest.2016.11.036. Epub 2016 Dec 6.

Peer reviewed by Thomas Davis.