What is the role of thiamine (Vitamin B1) in the treatment of septic shock?

From the Guidelines

Thiamine should be administered to patients with septic shock at a dose of 100-300 mg/day IV for 3-4 days, as recommended by the most recent guidelines. This is based on the latest evidence from the espen micronutrient guideline published in 2022 1. Thiamine plays a crucial role in cellular metabolism, particularly in the Krebs cycle and the conversion of pyruvate to acetyl-CoA, which is essential for energy production. In septic shock, patients often have unrecognized thiamine deficiency, which can lead to impaired oxygen utilization and lactate clearance, worsening tissue hypoxia and organ dysfunction. Thiamine supplementation may help correct this metabolic dysfunction, potentially improving cardiovascular function and reducing lactate levels. It is particularly important to consider thiamine in patients with risk factors for deficiency, such as malnutrition, chronic alcoholism, or prolonged critical illness. Thiamine has minimal side effects and a good safety profile, making it a low-risk intervention that could benefit patients with septic shock, especially those with elevated lactate levels. While administering thiamine, continue all other standard septic shock treatments including antibiotics, source control, and vasopressors as needed.

Some key points to consider when administering thiamine in septic shock include:

• The dose and duration of thiamine administration, as recommended by the guidelines
• The importance of identifying patients with risk factors for thiamine deficiency
• The potential benefits of thiamine supplementation in improving cardiovascular function and reducing lactate levels
• The need to continue all other standard septic shock treatments while administering thiamine

It is also important to note that the evidence for thiamine use in septic shock is still evolving, and more research is needed to fully understand its benefits and potential risks. However, based on the current evidence, thiamine appears to be a potentially beneficial adjunctive therapy in septic shock treatment.

The Surviving Sepsis Campaign guidelines do not specifically address thiamine use in septic shock, but they do emphasize the importance of early recognition and treatment of sepsis and septic shock 1. The guidelines also recommend the use of antimicrobial therapy, fluid resuscitation, and vasopressors as needed, but do not mention thiamine as a specific treatment.

In contrast, the espen micronutrient guideline published in 2022 provides a clear recommendation for thiamine use in patients with septic shock 1. This guideline is more recent and specific to micronutrient use in critically ill patients, making it a more relevant and reliable source of information on this topic.

Overall, the use of thiamine in septic shock is a promising area of research, and further studies are needed to fully understand its benefits and potential risks. However, based on the current evidence, thiamine appears to be a potentially beneficial adjunctive therapy in septic shock treatment, and its use should be considered in patients with risk factors for deficiency.

From the Research

Thiamine Use 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 has been linked to impaired aerobic respiration, cellular energy production, and increased lactate levels 2, 3.
• Several studies have investigated the use of thiamine supplementation in septic shock patients, with some showing improved lactate clearance and reduced mortality 4, 3.

Efficacy of Thiamine Supplementation

• A retrospective study found that thiamine administration within 24 hours of admission in patients with septic shock was associated with improved lactate clearance and reduced 28-day mortality 4.
• However, other studies have reported mixed results, with some showing no significant improvement in clinical outcomes with thiamine supplementation 5, 6.
• A randomized, placebo-controlled trial found no significant difference in kidney injury or mortality between thiamine and placebo groups, but patients who received thiamine had more ICU-free days 6.

Combination Therapy

• Some studies have explored the use of thiamine in combination with other micronutrients, such as vitamin C and corticosteroids, as an adjunctive therapy in septic shock 3.
• While initial results showed promising benefits, subsequent studies have failed to reproduce these findings, highlighting the need for further research into the optimal combination and dosing of micronutrients in septic shock 3.

Future Directions

• Further studies are needed to determine the optimal dosing, timing, and duration of thiamine supplementation in septic shock patients 5, 3.
• The use of multi-micronutrient administration, rather than single-micronutrient supplementation, may be a more effective approach in improving clinical outcomes in septic shock patients 3.