Vitamin C In The Critically ill- Are you aware of this miracle?

 


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Illustrative case

A 67 year old is admitted with acute coronary syndrome. PTCA was done and the patient improved. On day 3; TLC started rising and he developed hypotension, which was managed with antibiotics, inotropes and supportive care. He remained unweaned for 3 to 4 days. His LVEF was 35%.

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The point prevalence of critically ill is rising globally at a rate of 3.7 % to 9.8 % per year.

 

The main reason behind this is more supportive care facilities which extend the healing process or death before the final outcome.

 

Innumerable efforts are taken to improve the ICU outcome. Vitamin C is a low cost supportive care which has been shown to immensely benefit the critically ill from a wide range of illnesses.

 

During the 15th century scurvy was detected among sailors who did not consume fresh fruits and in the 17 century it was confirmed to be due to a dietary deficiency.

In the year 1930 Albert Szent-Györgyi discovered the chemical ascorbic acid—also known as vitamin C. By this time, vitamin was just considered anti scorbutic drug.

 

Recently Vitamin C has been recognized as a drug which benefits in almost anything which an ICU patients could have including the days on mechanical ventilation. A dose of more than 10 mg per day can prevent scurvy in adults. But in the critically ill the dose requirement is increased several folds.

 

In order to achieve a serum level of the normal individual’s (11 μ mol/L) Vitamin C requirement of the critically ill reaches up to 4 gms per day due to increased consumption.  

 

 

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In which conditions it helps?

 

Vitamin C has proven to have beneficial effects in the following conditions:

 

·         In septic shock- ↑ Blood pressure and reduce inotropes requirements

·         In heart failure- increased left ventricular ejection fraction and decreased the incidence of atrial fibrillation

·         On kidney - prevent real failure, protect against contrast-induced acute kidney injury,

·         Diabetes mellitus - decreased glucose levels in patients with type 2 diabetes mellitus

·         Respiratory - decreased bronchoconstriction, beneficial effect on pneumonia

·         ICU length of stay- Reduce the length of stay by up to 8.6%

·         Reduce the duration of mechanical ventilation up to 27%

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Is a serum level needed to prove deficiency?

 

No, Serum level is costly tests not routinely available everywhere. In the given circumstances, a serum level is not needed to start a therapy. Various study show that the serum levels are blow 11 μ mol/L in up to 20 % cases on admission, the levels drop dramatically below this and up to 4 gram per day may be needed to achieve this level.

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When to start?

 

As soon as the patient comes to ICU or needs mechanical ventilation.

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What route?

 

Both IV and oral is equally good.

 

 

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What Doses?

 

4- 6 grams per day

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Duration?

 

Five days or the duration of critical illness.

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Any adverse effects?

 

Diarrhea- in some cases on dose more than 2 gm per day.

Oxalate nephropathy- if dose more than 4 gm per day is continues for prolonged periods

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Cost

Tab Limcee 500 mg- ₹14 for 15 tabs

Injection Vitamin C 1.5 gm- ₹24 for 1 vial

 

 

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Ref:

https://www.ncbi.nlm.nih.gov/pubmed/30934660

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Are you prescribing Vitamin C in your ICU patients? When and what dose. Please share you experience.

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Dr. Prashant Kumar

MD, IDCCM, FNB (Critical Care), EDIC, ADHCA, DOA

Editor 'Critical Care WAarticles'

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