Reintam Blaser Annika, Alhazzani Waleed, Belley-Cote Emilie, Møller Morten Hylander, Adhikari Neill K J, Burry Lisa, Coopersmith Craig M, Al Duhailib Zainab, Fujii Tomoko, Granholm Anders, Gunst Jan, Hammond Naomi, Ke Lu, Lamontagne Francois, Loudet Cecilia, Morgan Matt, Ostermann Marlies, Reinikainen Matti, Rosenfeld Ricardo, Spies Claudia, Oczkowski Simon
Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.
Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
Acta Anaesthesiol Scand. 2023 Nov;67(10):1423-1431. doi: 10.1111/aas.14311. Epub 2023 Jul 27.
This Rapid Practice Guideline provides an evidence-based recommendation to address the question: in adults with sepsis or septic shock, should we recommend using or not using intravenous vitamin C therapy?
The panel included 21 experts from 16 countries and used a strict policy for potential financial and intellectual conflicts of interest. Methodological support was provided by the Guidelines in Intensive Care, Development, and Evaluation (GUIDE) group. Based on an updated systematic review, and the grading of recommendations, assessment, development, and evaluation approach, we evaluated the certainty of evidence and developed recommendations using the evidence-to-decision framework. We conducted an electronic vote, requiring >80% agreement among the panel for a recommendation to be adopted.
At longest follow-up, 90 days, intravenous vitamin C probably does not substantially impact (relative risk 1.05, 95% confidence interval [CI] 0.94 to 1.17; absolute risk difference 1.8%, 95% CI -2.2 to 6.2; 6 trials, n = 2148, moderate certainty). Effects of vitamin C on mortality at earlier timepoints was of low or very low certainty due to risk of bias of the included studies and significant heterogeneity between study results. Few adverse events were reported with the use of vitamin C. The panel did not identify any major differences in other outcomes, including duration of mechanical ventilation, ventilator free days, hospital or intensive care unit length of stay, acute kidney injury, need for renal replacement therapy. Vitamin C may result in a slight reduction in duration of vasopressor support (MD -18.9 h, 95% CI -26.5 to -11.4; 21 trials, n = 2661, low certainty); but may not reduce sequential organ failure assessment scores (MD -0.69, 95% CI -1.55 to 0.71; 24 trials, n = 4002, low certainty). The panel judged the undesirable consequences of using IV vitamin C to probably outweigh the desirable consequences, and therefore issued a conditional recommendation against using IV vitamin C therapy in sepsis.
The panel suggests against use of intravenous vitamin C in adult patients with sepsis, beyond that of standard nutritional supplementation. Small and single center trials on this topic should be discouraged.
本快速实践指南提供基于证据的建议，以解决以下问题：在患有脓毒症或脓毒性休克的成人中，我们是否应推荐使用或不使用静脉注射维生素C疗法？
该小组包括来自16个国家的21名专家，并对潜在的财务和知识利益冲突采用了严格的政策。重症监护、制定和评估指南（GUIDE）小组提供了方法学支持。基于更新的系统评价以及推荐分级、评估、制定和评价方法，我们评估了证据的确定性，并使用证据到决策框架制定了建议。我们进行了电子投票，要求小组中超过80%的人达成一致才能采纳一项建议。
在最长90天的随访中，静脉注射维生素C可能不会产生实质性影响（相对风险1.05，95%置信区间[CI]0.94至1.17；绝对风险差异1.8%，95%CI -2.2至6.2；6项试验，n = 2148，中等确定性）。由于纳入研究存在偏倚风险以及研究结果之间存在显著异质性，维生素C对早期时间点死亡率的影响确定性低或非常低。使用维生素C报告的不良事件很少。该小组未发现其他结局有任何重大差异，包括机械通气时间、无呼吸机天数、住院或重症监护病房住院时间、急性肾损伤、肾脏替代治疗需求。维生素C可能会使血管活性药物支持时间略有缩短（MD -18.9小时，95%CI -26.5至-11.4；21项试验，n = 2661，低确定性）；但可能不会降低序贯器官衰竭评估评分（MD -0.69，95%CI -1.55至0.71；24项试验，n = 4002，低确定性）。该小组判断使用静脉注射维生素C的不良后果可能超过有益后果，因此发布了一项有条件的建议，反对在脓毒症中使用静脉注射维生素C疗法。
该小组建议，除标准营养补充外，不应对患有脓毒症的成年患者使用静脉注射维生素C。应不鼓励开展关于此主题的小型单中心试验。
