From the Guidelines
Thiamine should be administered to patients with septic shock, particularly those with suspected thiamine deficiency, at a dose of 100-300 mg/day IV for 3-4 days, as recommended by the most recent guideline evidence 1. The role of thiamine in septic shock management is supported by its function as an essential cofactor for key enzymes involved in cellular energy metabolism. In septic shock, thiamine deficiency may develop due to increased metabolic demands, decreased intake, and impaired absorption, potentially worsening mitochondrial dysfunction and contributing to lactic acidosis. Some key points to consider when administering thiamine in septic shock include:
- Thiamine deficiency is common in critically ill patients and can develop within days of inadequate nutrition 1
- Low blood concentrations of thiamine have been reported at admission of critically ill patients with sepsis and septic shock 1
- Thiamine supplementation may help improve cellular oxygen utilization, reduce lactate levels, and potentially improve hemodynamics in some patients
- The administration of thiamine is generally safe with minimal side effects, making it a reasonable consideration in the complex management of septic shock, alongside standard treatments such as antibiotics, fluid resuscitation, and vasopressors However, it is essential to note that the evidence for universal benefit of thiamine supplementation in all septic shock patients is still evolving, and its routine use remains controversial. The most recent guideline evidence 1 recommends thiamine administration in patients admitted to emergency or intensive care without hesitation from admission for 3-4 days, with a grade of recommendation B and consensus of 80%.
From the Research
Role of Thiamine in Septic Shock
- Thiamine, also known as Vitamin B1, plays a crucial role in various biological processes, including glucose metabolism, nucleic acid synthesis, and reduction of oxidative stress 2, 3.
- Thiamine deficiency is common in critically ill patients, affecting up to 70% of them, and is associated with increased lactate levels, organ dysfunction, and poor clinical outcomes 4, 3.
Thiamine Supplementation in Septic Shock
- Thiamine supplementation has been investigated as a potential adjunctive therapy in septic shock, with some studies suggesting that it may improve lactate clearance and reduce vasopressor dose 3.
- However, current evidence does not support the use of high-dose thiamine as a single therapy or in combination with other micronutrients to improve clinical outcomes in septic patients 4, 5.
- A randomized controlled trial found that thiamine supplementation did not significantly reduce kidney injury or mortality in patients with septic shock, although it did increase ICU-free days 6.
Combination Therapy with Thiamine and Vitamin C
- Some studies have investigated the combination of thiamine and vitamin C as a potential therapeutic strategy in sepsis or septic shock 3, 5.
- A systematic review and meta-analysis found that the combination of thiamine and vitamin C did not reduce in-hospital mortality, but may improve SOFA scores and reduce the duration of vasopressor use 5.
Future Directions
- Further research is needed to determine the optimal dosage, timing, and duration of thiamine supplementation in septic shock, as well as its potential benefits and limitations in specific patient populations 4, 3.
- The use of multi-micronutrient administration, including thiamine, vitamin C, and other antioxidants, may be a promising area of investigation in the management of septic shock 3.