Spielen Vitamine bei der Pathogenese und Therapie der Sepsis eine Rolle?

Ulrich Häussler; Reimer Riessen; Michael Haap

doi:10.1055/a-0661-1112

DMW – Klinischer Fortschritt, Table of Contents

Dtsch Med Wochenschr 2018; 143(20): 1450-1454
DOI: 10.1055/a-0661-1112

Klinischer Fortschritt

Intensivmedizin

Spielen Vitamine bei der Pathogenese und Therapie der Sepsis eine Rolle?

Do Vitamins Play a Role in the Pathogenesis and Therapy of Sepsis?

Ulrich Häussler

¹Department Innere Medizin, Internistische Intensivstation, Universität Tübingen

²Department Innere Medizin, Abteilung für Gastroenterologie, Hepatologie und Infektionskrankheiten, Universität Tübingen

,

Reimer Riessen

¹Department Innere Medizin, Internistische Intensivstation, Universität Tübingen

,

Michael Haap

¹Department Innere Medizin, Internistische Intensivstation, Universität Tübingen

› Author Affiliations

Abstract

Was ist neu?

Vitamin B₁ (= Thiamin) Beim septischen Schock weisen erste Studien mit relativ kleinen Fallzahlen auf positive Effekte einer frühzeitigen Vitamin-B₁-/Thiamin-Substitution in Bezug auf Laktatclearance, Nierenfunktion und Letalität, insbesondere bei Patienten mit Thiaminmangel hin. Da ein Thiaminmangel bei Intensivpatienten häufig ist, sollte eine Thiamin-Substitution in ausreichender Dosierung bei allen Sepsispatienten mit Laktatazidose erwogen werden.

Vitamin C Vitamin C besitzt multiple biologische Funktionen, die sich im Rahmen einer Sepsis günstig auswirken könnten. Die Applikation von hochdosiertem Vitamin C in Kombination mit Thiamin und Hydrokortison war in einer viel diskutierten, 2017 veröffentlichten klinischen Studie mit einer drastischen Senkung der Sepsisletalität assoziiert. In mehreren prospektiven randomisierten Studien wird die Wirksamkeit dieses Therapiekonzepts derzeit unabhängig voneinander überprüft.

Vitamin D Auch der Einsatz von Vitamin D₃bei der Sepsis ist aus pathophysiologischer Sicht insbesondere bei Mangelzuständen ein vielversprechender Ansatz, allerdings ist der Wert einer therapeutischen Substitution derzeit noch nicht gesichert.

Abstract

Hospital mortality of severe sepsis and septic shock is still around 40 % according to recent studies. In accordance to the current sepsis definition, sepsis is a life-threatening organ dysfunction caused by a dysregulated response of the organism to infection. Septic shock is defined by vasopressor-dependent circulatory failure and lactic acidosis. Patients with sepsis and septic shock are often old and/or characterized by severe comorbidities, e. g. tumor or liver disease. These factors also predispose to malnutrition and hence to a corresponding deficiency of essential nutritional components e. g. vitamins. A number of recent studies and reviews have addressed the question whether deficiencies in certain vitamins may facilitate the transition from infection to septic shock. In addition, studies have investigated the effect of high-dose vitamin therapies on sepsis mortality and sepsis-associated organ dysfunctions. This article would like to summarize this current discussion with a focus on vitamin B₁ (thiamine), vitamin C and vitamin D.

Schlüsselwörter

Sepsis - Thiamin - Vitamin C - Vitamin D

Key words

sepsis - thiamine - vitamin C - vitamin D

Full Text

References

Literatur
1 SepNet Critical Care Trials Group. Incidence of severe sepsis and septic shock in German intensive care units: the prospective, multicentre INSEP study. Intensive Care Med 2016; 42: 1980-1989
2 Singer M, Deutschman CS, Seymour CW. et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315: 801-810
3 Amrein K, Oudemans-van Straaten HM, Berger MM. Vitamin therapy in critically ill patients: focus on thiamine, vitamin C, and vitamin D. Intensive Care Med 2018; [Epub ahead of print]
4 Marik PE. Vitamin C for the treatment of sepsis: The scientific rationale. Pharmacol Ther 2018; 189: 63-70
5 Belsky JB, Wira CR, Jacob V. et al. A review of micronutrients in sepsis: the role of thiamine, l-carnitine, vitamin C, selenium and vitamin D. Nutr Res 2018; 9: 1-10
6 Leite HP, de Lima LF. Metabolic resuscitation in sepsis: a necessary step beyond the hemodynamic?. J Thorac Dis 2016; 8: E552-E557
7 Manzanares W, Hardy G. Thiamine supplementation in the critically ill. Curr Opin Clin Nutr Metab Care 2011; 14: 610-617
8 Donnino MW, Andersen LW, Chase M. et al. Randomized, Double-Blind, Placebo-Controlled Trial of Thiamine as a Metabolic Resuscitator in Septic Shock: A Pilot Study. Crit Care Med 2016; 44: 360-367
9 Moskowitz A, Andersen LW, Cocchi MN. et al. Thiamine as a Renal Protective Agent in Septic Shock. A Secondary Analysis of a Randomized, Double-Blind, Placebo-controlled Trial. Ann Am Thorac Soc 2017; 14: 737-741
10 Holmberg MJ, Moskowitz A, Patel PV. et al. Thiamine in septic shock patients with alcohol use disorders: An observational pilot study. J Crit Care 2018; 43: 61-64
11 Marik PE, Khangoora V, Rivera R. et al. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest 2017; 151: 1229-1238
12 Galvin R, Brathen G, Ivashynka A. et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. Eur J Neurol 2010; 17: 1408-1418
13 Padayatty SJ, Levine M. Vitamin C: the known and the unknown and Goldilocks. Oral Dis 2016; 22: 463-493
14 Teng J, Pourmand A, Mazer-Amirshahi M. Vitamin C: The next step in sepsis management?. J Crit Care 2018; 43: 230-234
15 Spoelstra-de Man AME, Elbers PWG, Oudemans-Van Straaten HM. Vitamin C: should we supplement?. Curr Opin Crit Care 2018; 24: 248-255
16 Carr AC, Rosengrave PC, Bayer S. et al. Hypovitaminosis C and vitamin C deficiency in critically ill patients despite recommended enteral and parenteral intakes. Crit Care 2017; 21: 300
17 Fowler 3rd AA, Syed AA, Knowlson S. et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med 2014; 12: 32
18 Zabet MH, Mohammadi M, Ramezani M. et al. Effect of high-dose Ascorbic acid on vasopressor's requirement in septic shock. J Res Pharm Pract 2016; 5: 94-100
19 de Grooth HJ, Manubulu-Choo WP, Zandvliet AS. et al. Vitamin C Pharmacokinetics in Critically Ill Patients: A Randomized Trial of Four IV Regimens. Chest 2018; 153: 1368-1377
20 Gois PHF, Ferreira D, Olenski S. et al. Vitamin D and Infectious Diseases: Simple Bystander or Contributing Factor?. Nutrients 2017; 9 (07) E651 . doi:10.3390/nu9070651
21 Upala S, Sanguankeo A, Permpalung N. Significant association between vitamin D deficiency and sepsis: a systematic review and meta-analysis. BMC Anesthesiol 2015; 15: 84
22 Putzu A, Belletti A, Cassina T. et al. Vitamin D and outcomes in adult critically ill patients. A systematic review and meta-analysis of randomized trials. J Crit Care 2017; 38: 109-114
23 Amrein K, Schnedl C, Holl A. et al. Effect of high-dose vitamin D3 on hospital length of stay in critically ill patients with vitamin D deficiency: the VITdAL-ICU randomized clinical trial. JAMA 2014; 312: 1520-1530